I 




Class 


- ' v»/ • 


Book 




GofoTtelit N? 

copmugiit DEPosrr. 



ni< 



" // is wrong to trust the natural body to empirics, who com- 
///// have a few receipts whereon they rely, but who know 
neither the musts of diseases, nor the constitutions ofpatu nts, 
nor the danger of accidents, nor the true methods of cure.* 1 

Francis Bacon L561 1626). 



DISEASES 



OF THE 



SOFT STRUCTURES OF THE TEETH 
AND THEIR TREATMENT 

A TEXT-BOOK FOR STUDENTS AND PRACTITIONERS 



BY 

HERMANN PRINZ, A.M., D.D.S., M.D. 

PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS, THE THOMAS W. EVANS MUSEUM 

AND DENTAL INSTITUTE SCHOOL OF DENTISTRY UNIVERSITY OF 

PENNSYLVANIA, PHILADELPHIA 



ILLUSTRATED WITH 153 ENGRAVINGS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1922 



«% 



Copyright 

LEA & FEBIGER 

1922 



PRINTED l\ : i 8. A 

OCT 14*22 



PREFACE. 



In the following pages an effort is made to present to the student 
and practitioner of conservative dentistry a comprehensive study of 
the treatment of diseases of the soft structures of the teeth, based 
upon their clinical pathology. The difficulties which presented 
themselves to the author in systematizing the subject were the 
many conflicting statements as found in the literature. An attempt 
has been made to avoid vague information and to elucidate only 
clinical facts as related to the pathology of each individual disease 
and the subsequent application of rational therapeutic measures for 
its treatment. 

The first part of the book comprises the diseases of the dental 
pulp, while the second part will treat of the diseases of the peri- 
cementum including pyorrhea alveolaris. 

It is to be hoped that the second part will be available in the early 
spring of 1923. 

II. P. 

Evans' Institute, 
September, 1922. 



CONTENTS. 



Introduction 17 

CHAPTER I. 
Odontalgia 27 

CHAPTER II. 
Inflammation 3G 

CHAPTER III. 
Etiology of Diseases of the Dental Pulp 49 

CHAPTER IV. 
Classification of Diseases of the Dental Pulp 57 

CHAPTER V. 
General Principles of Diagnosis of Diseases of the Dental Pulp 62 

CHAPTER VI. 
Hypersensitive Dentin s 7 

CHAPTER VII. 
The Exposed Healthy Dental Pulp 103 

CHAPTER VIII. 
Hyperemia 110 

CHAPTER IX. 
Acute Simple Pulpitis 115 

CHAPTER X. 

Acute Suppurative Pulpitis 120 

CHAPTER XI. 
Secondary Pulpitis 124 



\ 111 



i ONTENTS 



CH M'Tl.i; XII. 

( Ihronk I u 11; \ 1 1\ i. Pi LPiTia 133 



(II \n l.i: Mil 

( !HRONI< \\\ PERPLAS1 U Pi LPITIS .... 



135 



( ii M'Ti.i: XIV. 
Di '.i \i ration of the Dental Pi lp 138 

CHAPTER XV. 

Di.\ 1 1 mi/ \i i..\ "i the Dental Pi lp .... 1 }1 

CHAPTER XVI. 

Mi \i\in i« \ i i.i* "i the Dental Pi lp ] ' ' 

CHAPTER XVII. 
Necrosis and Gangrene oi rHE Dental Pulp 159 

CHAPTER XVIII. 

Reinfection oi Rooi < w ^.ls — 

en u'Tki; XIX. 
Filling oi Rooi C -n us -'-' 

CHAPTER XX. 
Accidents Arising in rnE Treatment oi Root Canals 



DISEASES OF THE SOFT STRUCTURES OF 
THE TEETH AND THEIR TREATMENT. 



INTRODUCTION. 

The historical evolution of the practice of the healing art dis- 
tinctly indicates that it has always been governed by the ruling 
notions of general pathology. The early fathers of medicine regarded 
the body in its physiologic concept as being composed of the four 
elements of the philosopher Empedocles (490-430 B.C.), i. e., fire, 
water, air and earth. According to the hitter's conception all 
material substances in the world were composed of these four ele- 
ments. Basing their ideas of health and disease upon this philo- 
sophic doctrine, the ancient pathologists supposed that the body 
contained as an inherent property these four cardinal elements in 
the form of juices— the humors, i. e., blood (sanguis) phlegm 
(phlegmon), yellow bile (cholcr) and black bile (mrlancholor). It 
was assumed that life depended upon a proper mixture of these 
humors which constituted its well-being known as eucrasia. When- 
ever the normal equilibrium of the humoral mixture became dis- 
turbed, disease— dyscrasia— resulted producing abnormal tempera- 
ments— com/plexixmes— such as heat, moisture, dryness and cold, 
which in turn corresponded to the properties of the four original 
elements. As a consequence, this humoral conception of the nature 
of disease which was principally fostered by Hippocrates (460- 
377 B.C.) is referred to by the medical historian as humoral path- 
ology, and its predominating influence was recognized as late as the 
middle of the Fifteenth Century. A strong impetus was given to 
it by the famous Greco-Roman physician, Galen (130-201). He 
considered an abnormal condition of the blood as the primary cause 
of disease; to him any deviation from the normal indicated putre- 
faction and, therefore, his therapy centered about the administration 
of drugs which caused elimination, i. e. } cathartics, and in the 
regulation of the diet. The dogmatic influence of galenic therapy 
which held undisputed sway for more than fourteen centuries 
received a severe check by the introduction of chemistry into 
clinical practice by Paracelsus (1493-1541). Paracelsus taught 
doctrines essentially his own and strongly condemned the existing 
2 



L8 WTRODUCTIOh 

methods of teaching. He denounced the custom of blindly follow ing 
the teachings of < 'elsus, ( ralen, Avicenna and other orthodox n liters 
and, on the feast of St. John, I">l'7. the students having lit a bonfire 
in front of the University of Basel, Paracelsus seized the oppor- 
tunity to throw a copy of Avicenna's Canon in those days the 
leading work <>n the practice of medicine into the flames, saying: 

"Into St. John's lire, so that all misery may go into the air with 

the smoke." lie conceived the idea that disease was the result 
of abnormal manifestation of life. The spiritual principle of life 
arckoeus- is bound up with the body as a whole and consists of three 
elements: sulphur, mercury and salt. However, he used these 
terms in a purely symbolic manner. When an organic substance 
burns, that part which is destroyed by lire is sulphur, that which 
volatilizes and rises as smoke is mercury, and the ash is --alt. The 
resulting slag >ettle> in the various parts of the body like the tartar 
in the wine cask and causes tartaric diseases. The body juices 
become altered and blood poisoning acrimonia results and con- 
sequently, only physiologic therapeutics must he employed to 
reconstruct the dearranged system. In disease the archaeus has t<> 
hear the hrnnt of the burden, consequently Paracelsus' iatrochemi- 
ca] therapeutics centered about the reconstruction of this spiritual 
principle which is only possible by employing the spiritual force of 
medicinal substances— quint a essentia' which he isolated and dis- 
pensed in the form of tinctures and extracts— arcana. These arcana 
as obtained from plants and minerals must bear a certain specific 
resemblance or "signature" to the disease and are utilized as altera- 
tives which so favorably modify nutrition as to overcome morbid 
pro, < i Sylvius (1614-1672) was one of the strongest exponents 
of the theories of Paracelsus and materially assisted in the popular- 
ization of his teachings in France. The discovery of the circulation 
of the blood by Harvey I L578 L658) and the introduction of scien- 
tific methods in the study of morbid anatomy by Morgagni 1682- 
1 771 i which bore most excellent results in the hands of John Hunter 
(1720 L793) and Bichat (1771 L802) laid the foundation for the 
more' ready comprehension of the nature and causes of diseases. 

Andral (1787 1876), of Pari-, and Kokitansky (1804 1878), of 

Vienna, were the principal modern exponents of humoral pathol 

The teachings of Immoral pathology were by no means unh ersaty 
accepted. Almost simultaneously with it> inception we find the 
creation of ;i contemporary school which based its conception of 
disease upon the composition of solid natural organic and inorganic 
substances as conceived 1>\ the Greek philosopher Democrites 
ir.it b.c. . i. '.. the existence of atom-. Hi- doctrine centered 

about the h\ DOthesis that all material SUDStaU es were composed of 

these atoms, and, ;i> a consequence, the density of a mass depended 

upon the relationship of the spaces between their surfaces which are 



INTRODUCTION 19 

filled with air. Health— state strictus— is an expression of the nor- 
mal equilibrium of the affinity between atoms and space while 
disease— state laxas— indicates a greater or lesser density of the 
relative space occupied by the atoms. Medical historians refer to 
Democrites' conception of disease as solidary pathology; in general, 
it has received only meager support. 

Stahl (1660-1734) assumed that disease was an expression of the 
dearrangement of the immortal soul which controls all functions of 
the living body. This vitalistic pathology found its most ardent 
advocate in the then flourishing medical school of Montpellier 
(1700-1800) of southern France, and its teachings reached far into 
the nineteenth century. The well-knovn physiologist Johannes 
Mueller (1801-1858) was its last prominent exponent. 

Physiologists had observed that the soft tissues of the body, the 
muscles, were possessed of peculiar vital phenomena, which dis- 
tinctly differentiated living from dead tissues. It was left to 
Albrecht von Haller (1708-1777) to show that electric stimulation 
would cause contraction of the muscles and that this phenomenon 
was an expression of the increased sensibility of an irritated nerve. 
These observations had a most profound influence upon the con- 
ception of disease and in the annals of medical history it is recorded 
as neuropathology. 

Humoral pathology and so-called rationalism in therapeutic 
procedures were the two predominating factors which governed 
the practice of medicine and incidentally of dentistry at the begin- 
ning of the eighteenth century. This supposed rationalism started 
almost simultaneously in various parts of Europe. Sydenham 
(1624-1689), of London, Boerhaave (166S-1738), of Leyden, Van 
Swieten (1700-1772), of Vienna, Hoffmann (1660-1742)', of Halle, 
and Stahl (1660-1734), of Berlin, were the most influential expo- 
nents. The growing tendency of overdrugging received a healthy 
check through the introduction of Hahnemann's method (1810) of 
treating disease with very small doses and single remedies, which, 
combined with other extreme changes in therapeutics, resulted in 
the foundation of the homeopathic school. No definite knowledge 
regarding drug action had become available to the practising 
physician, and as a consequence of the empiric administration of 
drugs, it became quite customary to poke fun at those who regarded 
drugs necessary in the treatment of diseases. Especially Skoda 
and Dietl (1830-1870), of the Vienna school, expressed erratic views 
in regard to drug medication, and both extremists were wont to 
express their ill-founded skepticism by stating that: There are no 
real therapeutists— there are only lucky physicians. Bearing in 
mind the fact that no tangible knowledge of pharmacology existed 
at that time, our judgment of these outbursts of overzealous critics 
is materiallv modified when we consider that even at this dav the 



20 INTRODUCTIOh 

drugless "< Christian Scientist" and the supporter of the u Emmanuel 
movement" hold away in the minds of the credulous. 

Aboul the middle of the last century a complete change in the 
conception of the causes of disease and the subsequent administra- 
tion of remedial measures for their eradication occurred, which 
musl be primarily credited to the ingenuity of the master-mind of 
Rudolph Virchow L821 L902). His name will be forever indelibly 
engraved upon the annals of medical lore. The ready comprehen- 
sion of the present potabilities within the domain of clinical path- 
ology are made possible only by an intelligent study of his doctrine. 
The revolutionary change took place with the publication of his 
work. Cellular Pathology, in L858. "These lectures," ;1 ^ he stated 
in the preface of this classic in modern medicine, '"were particularly 
intended as an attempt to offer, in a better arranged form than 
had hitherto been done, a view of the cellular nature of all vital 
processes, both physiologic and pathologic, animal and vegetable, 
so as distinctly to set forth what even the people have long been 
conscious of namely, the unity of life in all organized beings, in 
opposition to the one-sided Immoral and oeuristical tendencies 
which have been transmitted from the mythical days of antiquity 
to "in- own time-,, and at the same time to contrast with the equally 
one-sided interpretations of a grossly mechanical and chemical 
bias the more delicate mechanism and chemistry of the cell-. 

Virchow's cellular pathology was founded upon certain observa- 
tions made by the anatomist Bichat, the originator of histologic 
research, who stated that life depended upon the physiologic inter- 
action of organic structures. Schleiden 1804 1881 . the botanist, 
and Schwann [1810 1882), the physiologist, had shown that all 
living tissues are composed of minute cell- and Remak I 1852) had 
formulated a law regarding the relation-hip of these cells to embry- 
onic life by stating: Omnia <tIInI<i e cellula. It is the recognition 
of tin- principle of cell begets cell, that enabled Virchow to con- 
struct hi- epoch-making concept of pathology which, in reality, i- 
merely a deviated physiology. 

The doctrine of cellular pathology as enunciated by Virchow is 

\,t\ slowlj l>nt steadily recognized within the specialized field o^i 
dental medicine and surgery. Such name- a- Wedl, Tome-. 
Saunders, Abbott, Magitot, Metnitz, Barrett, Burchard, Miller. 
Boedecker, Black and many others who are -till at work and too 
numerous to mention will forever be recognized a- leader- who have 
been or are -till actively engaged in assisting in the slow metamor- 
phosis which by necessity, dentistrj ha- to undergo to entitle it t.» 
the cognomen of a learned profession. 

Medicine i- sometimes considered a science and sometimes an 
ftr t. Both conceptions arc correct; it depends mere!) upon the 
viewpoint from which the subject is approached. Medicine is a 



INTRODUCTION 21 

science by its means of study and an art by its application. The 
object of medical science is to study disease; the aim of medical 
art is to cure disease, to relieve suffering and to maintain health. 
In general, it may be stated that the science of medicine is con- 
cerned with the study of the fundamental problems of biology as 
pertaining thereto, while the art of medicine treats of the study of 
disease, i. e., pathology, and the means and methods employed in 
relieving the sick and in favorably modifying the evolution of 
disease, i. e., therapeutics. The teaching of medical art as it is 
carried out on the sick constitutes clinics. 

Pathology, as stated above, is that part of medical science which 
embraces the study of diseases in all its aspects and explains the 
origin, cause, clinical history and nature of the various morbid 
conditions which may disturb the economy and, consequently, it is 
the composite of numerous subdivisions. 

Etiology is concerned with the study of the causes of diseases. 
Morbific causes may be internal or intrinsic, external or extrinsic, 
ordinary, specific, primary or secondary and exciting. These causes 
may also be classified as being predisposing or determining. Pre- 
disposing causes may prepare the body or a part thereof by render- 
ing it weak and less resistant, while the latter are the immediate or 
specific causes of disease. Pathogeny tries to explain by what 
mechanism these causes act on the living organism by disturbing 
the state of its health and by abolishing its resistance. Morbid or 
pathologic anatomy discusses the changes of the tissues after death 
and pathologic physiology portrays the morbid reaction of the living 
organisms from pathogenic causes. Symptomatology furnishes an 
account of the signs and symptoms appreciable during life, while 
nosology describes and classifies disease. Symptoms may be objec- 
tive or subjective; objective when evident to the senses of the 
observer, as redness, swelling, high temperature, etc.; subjective 
when felt or known only by the patient, as pain, nausea, etc. The 
prodromes are the earliest recognizable symptoms, as rigors and 
chills during the invasion of fever while sequels are morbid phenom- 
ena which are left as a result of disease. Syndromes represent the 
aggregate of the symptoms associated with any morbid condition, 
and together they constitute the picture of the disease. An acute 
disease is one in which the invasion is sudden and rapid and, as a 
rule, severe; when the symptoms develop less rapidly and are less 
intense the disease is said to be subacute. If the disease is very 
slow in unfolding its salient features with an obscure blending of 
the various symptoms it is said to be chronic. 

Diagnosis, or discrimination of the disease, determines the place 
which it occupies in nosology and prognosis tries to fortell its evolu- 
tion. A complete diagnosis includes: (1) The naming of the 
disease; (2) the recognition of its state, peculiarities and compli- 



22 /\ TRODUCTIOh 

cations; and (3 the estimation of dangers existing or liable to arise. 
In a direct diagnosis the morbid condition is revealed by ;i combina- 
tion oi clinical phenomena or b) sj mptoms belonging to a particular 
disease and hence they are termed pathognomonic symptoms \ 
differential diagnosis results Prom the elimination of diseases resem- 
bling each other, while ;i diagnosis by exclusion proves the absence 
of all diseases which might give rise to the symptoms obsen ed, with 
the exception of one the presence of which is not actually indicated 
by any positive signs. The diagnosis is the tnosl important and, 
incidentally, the most difficult part of the art of medicine. It 
reflects all the various steps involved in the study of disease and 
in the correlated sciences. The use of the microscope, instruments 
of precision, chemical and bacteriologic tests, roentgenograms and 
numerous other adjuncts have been utilized in the construction of 
tin 1 foundation upon which a Large part of our knowledge of patho- 
logic processes is built and by it and through it diagnosis has been 
placed upon a rational basis. The introduction of the electric 
current as a diagnostic aid in the recognition of diseases of the pulp 
should be considered as one of the mosl important advances in the 
practice of dental therapeutics. 

The ultimate object of the clinical practice of medicine is to be 
able to cure, to relieve and to prevent disease, i. >.. the application 
of therapeutic measures. Therapeutics does not consist solely of 
t 1h- administration of drugs, but it requires a comprehensive knowl- 
of surgery, prophylaxis and dietetics. The application of 
remedial substances in the treatment of diseased condition- is based 
on a knowledge of pharmacology, and at present it is referred to as 
pharmacotherapy, while surgery is that branch of therapeutics which 
endeavors to cure by manual procedures. Prophylaxis, whose 
principal part is represented by hygiene, dictate- the precept- to 
be followed in avoiding disease and dietetics indicates the diet con- 
ducive to the restoration and preservation of health. 

Nomenclature, i. e., the naming of diseases, is an important 
division of general pathology. Name- of diseases, like name- iA 
other things, have originated in a variety of way- and have under- 
gone many changes at the hands of the generations who have 
suffered from diseases. Some, like Harlow's disease or Blight's 
disease, have received the names of their supposed discoverer, while 
other-, like paralysis agitana are called for some pronounced sign or 
symptom. Epulis, as its etymology indicates, was employed by 
Galen to designate a tumor growing upon the gum, while parulis 
wing beside the gum was used by him to signify a gum boil 
chronic alveolar abscess). Again, the term malaria had air. 
referring to the theory ^i the miasmatic origin of the disease was 
used t<> refer to some apparently causal condition. A few names 

have had a more -cut iniciit al origin for in-tancc. syphilis, which 



INTRODUCTION 23 

gets its euphonious title by way of a poem of a sixteenth century 
physician, named Fracastorius. A shepherd, named Syphilis, was 
stricken with the disease by Apollo, in punishment for paying divine 
homage to the king instead of to the god. The disease stuck to the 
shepherd and somehow the shepherd's name became firmly attached 
to the malady. 

The real value of medical nomenclature consists in choosing a 
name that shall suitably express the involved morbid condition, and, 
if possible, its location. Unfortunately, this is not always possible, 
since numerous terms by virtue of their antiquity are still retained, 
as carcinoma, sarcoma, etc. 

Inflammation.— The significance of inflammation is usually ex- 
pressed by adding the suffix Uis to the name of the anatomical 
structure involved, thus if the disease be an inflammation of the 
pulp, it is termed pulpitis. 

Pain without Inflammation. — The significance of pain without 
inflammation is usually expressed by adding the suffix algia to the 
name of the anatomic structure involved. Thus, if the disease 
be a morbid condition of the nerve tissue without inflammation, it 
is termed neuralgia. Occasionally, the suffix dynia is employed to 
describe a similar condition. Thus, pain in the tongue without 
inflammation is referred to as glossodynia. 

Catarrh. — The significance of a morbid condition indicating the 
formation of an inflammatory transudate escaping to a mucous 
surface, known as catarrh, is usually expressed by adding the suffix 
rhea to the name of the transudate or flux. Thus, if the disease be 
a morbid condition of the alveolus of a tooth associated with a flow 
of pus it is termed pyorrhea alveolaris. 

Dropsy. — The significance of an excessive accumulation of watery 
liquid in a tissue or cavity of the body is usually expressed by adding 
the prefix hydro to the anatomic name of the involved structure. 
Thus, if the disease be an accumulation of a dropsical transudate 
within the maxillary antrum it is termed hydrops antri Highmori. 

Blood Diseases. — To signify a morbid condition of the blood the 
suffix emia is usually employed. Thus, if the disease be an impov- 
erishment of the blood it is termed anemia; if blood contains an 
accumulation of urea the disease is designated as uremia; a putrid 
infection of the blood is designated as septicemia; a purulent infec- 
tion as pyemia, etc. The significance of a flow of blood, hemorrhage, 
from an anatomic structure is usually expressed by adding the 
suffix rhagia to the name of the involved tissue. Thus, if a 
hemorrhage occurs from the small intestines it is termed enteror- 
rhagia. 

Changes in the Urine.— The significance of alteration in the urine 
is usually expressed by adding the suffix uria to the noun indicating 
the change. Thus, the term albuminuria indicates the presence of 



24 I \ TRODl < TlOh 

albumin in the urine; hematuria, when blood Is present in the urine, 
etc. 

Tumors. The suffix oma signifies a tumor, as osteoma, a bone 
tumor; fibroma, a fibrous tumor, etc. 

The termination of diseased conditions maj occur in one of 
three ways, i. e., cure, secondary processes or death. A cure may 
manifest itself as lysis, i. e., a -low return to health or a- crisis, i. >.. 
an abrupt change for the better. Secondary processes are those in 
which the diseased condition i- substituted by a morbid process, as 
infection of the pericementum followed by a tonsillitis. Metastasis 
indicates a shifting of a disease or its local manifestations from one 
part of the body to another. 'The complete cessation of all tissue 
changes is known as death. It may manifest itself a- an ever 
increasing debility, asthenia (cancer. Blight's disease ; as an 
insufficient quantity or quality of blood, anemia: as a non-aeration 

of the blood, apnea (croup); or as death beginning at the brain, 

coma (uremia, narcotic poisoning). 

Health and disease (ease and dis-e&se) are relative concepts con- 
currently employed to designate states which differ in their mani- 
festations without creating a sharp line of demarcation. Perfect 
health does not exist; the living organism is always in a state of 
unstable equilibrium which finds its cause and explanation in the 
very conditions of life. Living matter does not depend upon a vital 

force, but it should be considered as reactions produced by the 
variations of external stimuli. 

Numerous colloquial metaphors are utilized to define health and 
disease. For instance, a clergyman has referred to it a-: Health 
is harmony, disease discord. Roger I L898) define- disease a- being 
the ensemble of the phenomena which are produced in an organism 
undergoing the action of a morbific cause and reacting against it. 
Adami I L908) refers to disease as being the expression of a reaction 
on the part of the cells to injurious agencies, while someone else 
ha- stated that disease is a morbid process considered in it- entire 
evolution, /". e., from its initial cause to it- final consequence. In 
short, disease may be defined a- expressing the morbid changes 

which occur when normal tissues react to abnormal influences, 
thus Constituting a definite entity. 

It i- generally conceded at present that disease may be pro- 
duced by mechanical, physical, chemical, electric and animate 
causes and that their initial impulses must be looked for out-ide of 

the organism. The lesions as they are produced 1>.\ these causes do 
not necessarily remain local; secondary morbid manifestations are 
most frequently observed as direct sequences. Local causes are 
usually acting upon a limited point of the organism, while general 

Causes ma\ act on the entire economy or rather on numerou- points 

thereof. [x>cal causes ma\ produce their distinct phenomena at 



INTRODUCTION 25 

the point of application or they may give rise to disturbances in 
distant parts of the body. 

The intelligent application of rational therapeutic measures in 
the treatment of diseases necessitates a comprehensive realization 
of the gradual development of its underlying phases, i. e., clinical 
pathology. In the following pages an attempt is made to harmonize 
the broad principles of the practice of general medicine with that 
of the specialized field of dental surgery. 

In his legal qualifications the dentist is regarded as practising 
within the compass of a specialized department of the science and 
art of healing, therefore, it behooves him to thoroughly familiarize 
himself with the general principles underlying the practice of 
medicine. Hence, in presenting a discussion of the various dental 
ailments the writer, in conformity with long-established customs 
of the practice of the medical art, has adopted the following outline 
setting forth the salient features in their routine sequences and 
presenting to the student a complete picture of the respective 
disease as a whole, relatively speaking, by a detailed interpretation 
of the clinical aspects of each subject. 

Outline of Dental Diseases. 

Name of the disease and its synonyms. 
Definition of the disease. 
Etiology of the disease. 
Clinical pathology of the disease. 
Symptoms of the disease. 
Complications and sequels of the disease. 
Diagnosis of the disease. 
Prognosis of the disease. 
Treatment of the disease. 



PART I. 
DISEASES OF THE DENTAL PULP. 



CHAPTER I. 
ODONTALGIA. 



Odontalgia, toothache, as its name indicates, is, in . the 
majority of cases, the most pronounced symptom of an existing 
dental disturbance. Toothache, in most instances, is the prime 
motive which induces the patient to seek the sen ices of the dentist. 
The relief of the painful condition is his principal desire; to him 
the conservation of the tooth is, in many instances, a secondary 
consideration. It is the paramount duty of the practitioner to 
ascertain, if possible, the cause of the existing pain. He should 
look upon the aching tooth and its surrounding structure from a 
biologic point of view, as pain is a manifestation of a vital reaction 
and, consequently, he should draw upon all the facilities which are 
offered to him through his knowledge of the medical art so as to 
be able to institute correct therapeutic procedures for the allevia- 
tion of the symptoms of the existing disease, and, if possible, for the 
eradication of its cause. 

Odontalgia is not a disease; it is the subjective painful expression 
of some pathologic disturbance within the tooth or its surrounding 
structures. Its etiologic factors may be classified as local, or 
primary, general, or secondary, and as reflex disturbances. In 
the majority of cases it will be observed that toothache is the 
sequence of an inflammatory disturbance within the tooth, i. e., 
its pulp, or within its external retentive structure, i. e., pericemen- 
tum. These two important centers of sensation usually may be 
distinctly differentiated in regard to the subjective manifestations 
of pain and in regard to the objective symptoms of pathologic 
alterations. A distinct and clear line of demarcation between the 
two clinical pictures, i. e., pulpitis and pericementitis, relative to a 
differential diagnosis should, in the present light of pathologic 
knowledge, offer no difficulties. As a third group, which, however, 
quantitatively, is by far overshadowed by the first two groups, we 



28 DISEASES OF THE DENTAL PULP 

encounter the reflex odontalgias. While this type of toothache, 
as stated, is of a comparative rare occurrence, it is, nevertheless, 
usually verj severe in it- manifestations and, incidentally, mos1 
difficult to diagnose. A detailed discussion of the known facts are, 
therefore, of paramount importance to the clinical practitioner. 

The various causes of the diseases of the pulp ;m<l the peri- 
cementum, their symptoms, clinical pathology and treatment are 
discussed in detail in the succeeding pages. Odontalgia at this 
moment is merely recorded as a clinical entity so as to present to the 
reader a comprehensive summary of its manifested symptomatology. 

The causes of odontalgia maj he summarized as follows: 

Hypersensitive Dentin. It may he defined a- a state in which 
the exposed dentin of a vital tooth is painfully responsive to any 
type of irritation. (Clinical pathology and treatment, -(•«• ]». 87, 
etal.) 

Pulpitis. Inflammation of the exposed or unexposed dental pulp 
in its numerous modification- may he caused primarily 1>\ mechani- 
cal, chemical, thermal, electric or parasitic irritation. Secondarily, 
it may have it^ origin in the disturbances of the pericementum, or it 
ma\ be the sequence of some general disease. (Clinical pathology 

and treatment, see p. 110 ei al. I 

Secondary Pulpitis. Secondary manifestations of pain within the 
pulp of a tooth are of very common occurrence; they may be caused 
by a primary existing local disturbance within the body of the 
dental pulp or by a general disease. In the majority of cases of 

Secondary pulpitis the causative agent is a direct or an indirect 

infection, although general diseases of a non-infectious type, such 
as a leukemia, locomotor ataxia, anemia, chlorosis, increased intra- 
dental blood-pressure and various neuropathic conditions, as 
hysteria, neurasthenia, etc., may he the exciting factor-. Clinical 
pathology and treatment, see i>. L24, ei al. I 

Pericementitis. Inflammation of the pericementum may be 

caused by any type of direct irritation or, secondarily, by local 

disturbances, i. <.. pulpitis or gingivitis, or as a sequence of some 

ral diseases. (Clinical pathology and treatment, see p. 300, etal. | 

Hyperplasia of Cementum. Pathologic overgrowth of cementum, 
frequently referred to as exostosis or hypercementosis, is usually 
more often found about the root- of the upper teeth. Externally, 

Usually nothing can he -ecu which would furnish a cine to its 

diagnosis; onlj in cases of severe enlargement of the cementum 
bulging of the gum tissue over the affected tooth maj be observed. 
The pain is usually very indefinite, of a dull, continuous, neuralgi- 
form character and not localized. Occasionally, it ma\ he very 

excruciating or it ma\ manifest itself as a gnawing paroxysm recur- 
ring at irregular intervals. Thermal changes and percussion are 
tive. Hyperplasia of cementum should be looked upon as a 



ODONTALGIA 



29 



product of defense instituted by the cementum to protect itself 
against chronic irritation. It is the analogue of the formation of 
adventitious dentin in the pulp. The diagnosis is very readily 
made from a roentgenogram. Treatment: Removal of the tooth 
or amputation of the affected root. 







Fig. 1. — Hyperplasia of cementum. (Burchard.) 

Disturbed Articulation. — Faulty restoration of a defect of the 
crown of a tooth by operative procedures may he its direct cause 
or, if for any other reason a tooth receives a greater impact during 
closure of the jaws than normal, a painful traumatic pericementitis 

may result. Treatment: Restoration of normal articulation. 




Fig. 2. — Hyperplasia of cementum. 

Impacted Teeth.— Impacted teeth usually do not cause painful 
symptoms unless they meet on their path of retarded eruption an 
obstruction or they exert pressure upon nerve fibers. The painful 
symptoms may he of a neuralgiform character or they may be 
manifestations of a traumatic pericementitis. Occasionally, epilep- 
tiform attacks may be observed. The lower third molars, and less 
so, the upper third molars are most often found to be hampered on 
their ways through the alveolar process. The "Ahasuenis" among 
the permanent teeth is the upper canine. In its vicarious excur- 
sions it may erupt anywhere about the maxilla and at any age. 
Although fully developed, the tooth may lie dormant within the 
body of the jaw for years, or, when irritated by pressure or otherwise, 
may at any time start on its erratic journey to the periphery. The 
writer has had occasion to remove impacted canines from every 



30 DI8E ISB& OF THE DENTAL PULP 




Fiq. :;. —Impacted and malformed second incisor. 




Flo. l. —Impacted lower third molar. 




[mpacted upper canines. 



ODONTALGIA 31 

available surface of the hard palate, from the nasal cavity and from 
the maxillary sinus. In one case the vagrant made its appearance 
at the age of sixty-five in an edentulous jaw over which a plate had 
been worn for more than thirty years. Impacted teeth frequently 
show marked absorption lacunae; genuine caries, however, has 
probably never been observed. 

Root remnants left in the jaws and fractured teeth have been 
very frequently obstinate sources of most obscure pain. Usually, 
an existing fistula will assist in locating these broken roots; on rare 
occasions the fistula may be absent. A roentgenogram will clarify 
the diagnosis in both instances. Treatment: Removal of the ob- 
struction or of the impacted tooth or root remnant. 




Fractured upper incisors. 



Overstrain of Single Teeth.— Single teeth standing in a broken 
arch frequently are overstrained during the process of mastication. 
If the antagonists of the tooth are missing the tooth may elongate 
in its socket and thereby expose its root or roots or it may cause 
traumatic injury of the opposing alveolar ridge. The continuous 
impact on these teeth during mastication may cause inflammation 
of the pericementum with all its sequences, while its exposed roots, 
being denuded of the protective alveolar process and cementum, 
becomes frequently most excruciatingly hypersensitive. Treat- 
ment: Prosthetic replacement of the lost teeth or extraction. (The 
treatment of hypersensitive dentin is discussed on p. 87, et ah) 

"Setting Teeth on Edge."— This popular expression as employed 
by the laity denotes a state of irritation of the pulp brought about 
by the action of organic acids taken as condiments or being present 
in foodstuffs upon denuded dentin surfaces. Upon sound enamel, 
ordinary fruit acids or vinegar (5 per cent acetic acid) do not pro- 
duce painful impression. This phenomenon, as expressed in the 
words of the Prophet : " Every man that eateth of the sour grape 
his teeth shall be set on edge," may also occur as a somatesthetic 
manifestation of a disturbed psyche. Treatment: Protection of 
the enamel defect by mechanical or therapeutic measures. 

Reflex Odontalgia.— Genuine neuralgia arising from dental causes 
is extremely rare, while neuralgiform types of pain in and about the 



.';_ ) DISEASES OF THE DENTAL PULP 

teeth are more often observed. Neuralgia should !><• looked upon 
as a neuropathic disturbance <>t* nerve fibers without having any 
direct connection with an organic disease. True trifacial neuralgia, 
sometimes referred to as tic douloureux, FotherguTs disease or pro- 
sopalgia, manifests itself l>.\ a sudden paroxysmal pain of a sharp, 
darting, stabbing character, which is most common along the course 
of ilif supra- and the infraorbital branches of the left side of the 
face with increased lacrimation, slight edema, gray eyebrows and 
convulsive twitches and tenderness at the intra- and supraorbital 
foramina (points douloureux), as well as along the course of the 
nerve distribution. It is most often restricted to women of middle 
age in which neuropathic disturbances or a general disease, prin- 
cipally anemia or hyperesthesia of pregnancy, play predominant 
roles. Neuralgia should be differentiated from neuritis, i e. t an 




T> pica! position of hands in tic douloureux. I Mayrhofer.) 



inflammation of a nerve trunk, prima rely characterized by continu- 
ous pain, impaired sensation, motor paralysis and atrophy. < 'entral 
trifacial neuralgia, either from involvement of the ganglion itself 
or its internal roots, or a> a result of pressure from a cerebral tumor. 
/. i., a neuroma, often leads to a fault} diagnosis of toothache. 
Mam patients suffer the loss of one tooth after another in the vain 
search for the real cause. After the sacrifice of the teeth the dentist 
or physician maj wake up to the fact that the painful disorder is of 

a central origin, and that a grave mi-take has been made. 

Neuralgiform types of pain in and about the teeth of an obscure 
character are occasionally met with. The true cause of the pain 
m;i\ he located anywhere between the origin of the nerve in the 
brain and it - end-organs, i.e., in our case, in the teeth or within their 
immediate surroundings; however, the sensation of pain i^ only 



ODONTALGIA 33 

manifested at the periphery. If a carefully conducted diagnosis by 
exclusion has eliminated every one of the above discussed factors, 
one should be mindful of the possible presence of solid new growths 
within the body of the pulp, which are referred to as adventitious 
dentin if attached to the wall of the root canal or as pulp stones or 
nodules, denticles, internal odontomes, dentinoids, etc., if sus- 
pended within its body. The formation of pulp nodules is most 
likely always due to some type of mild, continuous external irrita- 
tion which excites the dentin-forming cells of a healthy and, usually, 
mature pulp to renewed activity. This irritation, however, must 
never become severe enough to produce acute inflammation. These 
pulp nodules usually represent pearl-like, shiny beads; they are 
found singly or multiple and occasionally a few may coalesce into 
an irregular multiple mass. The pulp chamber as well as the root 
canals serve as their abodes. Regarding their location in the 





Fig. 8. — Pulp stone removed from an Fig. 9. — Pulp stone in situ. 

upper molar. Normal size. Upper incisor. 

various types of teeth, it has been observed that the incisors and 
canines are relatively seldom invaded, while the pulps of premolars, 
but primarily the molars in mature age, are principally selected as 
seats of their formation. Dieck 1 state that he lias found pulp 
nodules in more than 18 per cent of extracted molars and premolars, 
counting only those teeth which contained macroscopically observ- 
able deposits. By their mere presence and close contact with nerve 
filaments within the pulp these nodules may cause chronic pressure 
and, as a consequence, more or less severe pain which steadily 
increases with their growth. Pulp nodules have been observed in 
root canals which completely occluded their lumen and thereby 
caused atrophy of the severed pulp stump. 

To attempt a correct diagnosis of pulp nodules in a tooth in situ 
is a most hazardous undertaking. The antecedent history furnishes 
little information; the age of the patient is of some importance, i. e., 

1 Ueber den dentalen Ursprung der Prosopalgic, Wuerzburg, 1897. 
3 



;;i DISEASES OF THE DENTAL PI LP 

pulp stones are rarely observed below twenty. Frequently, the age 
is the only available clue. Exploration and inspection may bring 
to light ;i few additional meager data. The suspected tooth usually 
shows -«»iiic ext <Tn;i 1 defect whieli iimy serve as a focus for the 
necessary mild irritation which is responsible for the formation of 
the nodule, /. r., abrasion, erosion or premature senile atrophy of 
the protecting alveolar process and, occasionally, dental caries. It 
is characteristic of teeth containing nodules that thej present t\ pica! 
senile appearance, and on sectioning always show the /one of 
translucency. Transillumination Is usually negative as the thick 
body of a molar crown oilers a high resistance to the passage <>t' the 
raj s of even a very high power dental lamp. ( Conductivity of tem- 
perature and percussion reveal very little information, although 
cold applied In the form of the ethyl chlorid spray may cause a 
painful paroxysm. Dentz 1 lauds the application of cold as pos 
ing specific merits in diagnosing pulp nodules in an other* ise sound 
tooth. It is claimed that when a tooth responds more painfully on 




Fig. 10. Pulp stones in situ. Upper molars. 

percussion during a cycle of pain, and this hyperesthesia passes off 
immediately after the paroxysm ceases, pulp nodules may be sus- 
pected. On testing a tooth pulp containing nodule- with the 
electric current usually a slight abnormal sensation is discerned 
which indicates hyperemia or acute partial pulpitis. However, not 
too much reliance must be placed upon such slight differences. A 
good, well-defined roentgenogram is an absolute prerequisite for a 
diagnosis. The interpretation of a light shadow within a pulp 
chamber should not, however, be too hastily pronounced a pulp 
nodule. 

The localization of the existing pain and its manifested character 
is of the utmost importance. In the very earlj stages of an existing 
pain about a tooth, one is usually more readily able to distinctly 
locate the afflicted member. In the Inter periods there is always 
a possibility of irradiation. A very carefully conducted inquiry in 
!«1 to the subjective symptoms of the existing pain may lead 

1 Tijdaohrift voor Tandheelkunde, 1904, p. 231. 



ODONTALGIA 35 

to most valuable hints in regard to a differential diagnosis. The 
patient may describe his pain as being of a severe acute throbbing 
or lancinating character, often occurring at specific intervals, usually 
toward evening, or of a milder chronic type. The paroxysm may 
last for a minute or two, or longer, and the affected side of the face 
becomes flushed. The absence of convulsive twitches, gray eye- 
brows, sex, age and the nature of the paroxysm, etc., differentiates 
dental neuritis from trifacial neuralgia. 

To differentiate true central trifacial neuralgia from peripheral 
dental neuralgiform types of pain, i. e., dental neuritis, local anes- 
thesia is frequently an efficient aid. If during an attack the sup- 
posed painful area is blocked out by a local anesthetic and the 
paroxysm ceases for some hours, one may be reasonably assured 
that the disturbances lie within the region of the blocked-out teeth, 
while if the pain presently returns, one has to deal with a central 
affection of the facial nerve. After the pulp of a tooth has been 
destroyed, referred pains cease and there are only manifestations 
of local pains, due to an involvement of the peridental structures. 



CHAPTER I I. 

INFLAMMATION. 

Inflammation of the dental pulp In its fundamental principles 
does not materially differ from the orthodox doctrines accepted at 
present by the leading pathologists. According to the classic 

definition of Burdon Sanderson, Inflammation may be defined as 

"the local reaction to an injury," i. c, t Ik* reaction of an irritated 

or damaged tissue. The irritated tissue must, of necessity, -till 
possess its vitality. It Is generally conceded at present thai inflam- 
mation is not, in the strict etymologic sense of the term, a disease; 
it is the sequence of an irritation which manifests it-elf in the local 
defence, /. c, a protective reaction against the invading foe. "The 
condition of local flaming inflammatio has, of necessity, been 
recognized from the very beginning of medical studies, hut so long 
a- little was known concerning the causes of disease and less regard- 
ing the processes, all that could he accomplished was to regard this 
a> a state characterized by certain peculiar symptoms, and the first 
attempt- of a definition, that of Celsus and Galen, so regarded it. 
Inflammation, they laid down, was a condition characterized by 
rubor, fun/or, dolor, color redness, swelling, pain and heat to 
which definition later writers added a fifth cardinal symptom of 
functio hisd, disturbed function." (Adami.) 

Before entering into a detailed discussion of the various manifesta- 
tions of disturbances of the pulp, it seems advisable to review in a 
preliminary way the modern pathologic conception of inflammation. 
Elsewhere the writer has stated that the most important changes 
occur in the bloodvessels, which are distended by an increased flux 

of blood; this manifestation is, however, very quickly changed by 
a retarded afflux. The white corpuscles conglomerate in bunches 
near the \e>sel wall, especially in the veins and capillaries, while 
the red Mood corpuscles keep to the center of the Mood stream. 
The leukocytes and the lymphocytes now pa-- between the endo- 
thelial cells through the vessel wall of the veins and of the capillaries, 
but not of the arteries. This wandering of the white corpuscles 
dia j »< 1 1 sis is accomplished bj a transudation of blood serum, which 
fills the surrounding tissue-, causing an edematous swelling. Later 
on ih<- red corpuscles follow, but the} migrate in much smaller 
quantities. The nature of the transudate, the quantity of the 

blood corpuscles and the admixture of foreign bodies determine 



INFLAMMATION 



37 



the character of the infiltration, as it may be a serous, fibrinous, 
purulent, hemorrhagic or croupous exudate. Another important, 
but usually less recognized, symptom of inflammation is the 
increased osmotic pressure within the infiltrated area. Under 
normal conditions the osmotic pressure within the soft tissue is 
promptly regulated by the organism, probably, according to 
Massart, through specific nerves, i. e., the normal equilibrium of 
the isotonic index of the blood and tissue fluids remains stationary. 
In pathologically altered tissues the composition of these fluids is 
continually interfered with, and usually results in a marked increase 
of osmotic pressure, i. c, hyperisotonicity. Increased osmotic 




Fig. 11. — Inflamed mesentery of frog: a, marginatum of leukocytes in the dilated 
capillaries; b, migration of leukocytes; c, escape of red corpuscles; d, accumulation of 
leukocytes outside the capillaries. (After Ribhert.) 



pressure induces pronounced morphologic changes in the cells, and 
is largely responsible for the resultant pain, followed by inflamma- 
tion, within the affected area. "We know that the lumina of the 
vessels in inflamed areas are increased much beyond their normal 
size, so that the combined area of the lumina of the vessels within 
the inflamed area is several times the area of the lumina of the vessels 
entering the part; and the systolic pressure is as much greater in 
the part as the area of the vessels in the part is greater than the 
area of the vessels entering it. This is according to a well-known 
principle of mechanics. To be more definite we may assume the 
area of the lumina of the entering vessels to be one square foot, and 



38 



DISEASES OF THE hi. \ TAL PULP 



the area is the same as thai <>n the small area. Therefore, it will 
be twenty times the smaller pressure (for example, if the smaller is 
one pound, the larger will be twenty pounds). Thus, it is easy to 
understand how the Increased area of the vessels will indirectly 
cause the sensation of throbbing. It would further cause compres- 
sion of any nerve fibers which are found in the organ, and would 



nt'-ring part 



Ar. 3 thirty titnc3 that 
of small . 
th 3 part. 




Arua of vossu 
in inflamed part. 



Fig. 12. Method of i>;iin production in inflammation. 

also undoubtedly exert a great pressure upon the capsule. Hotli of 
the factors would produce pain." (Helian.) If a simple al» 
were taken as an example, the various changes in the tissues could. 
according to Hitter, be described as follows: In the center of the 
pus cavity the osmotic pressure may reach a density of 0.6° C. 
to 1.4° ( ' . (0.56° ( '. being normal), lmt in the surrounding hyperemic 
zone the pressure is less, gradually diminishing in the manifest 




l.; Schematic drawing of an abscess. The abscess and the surrounding 
infiltrated area show the various degrees of osmotic pressure, o, abscess; 6, hyperemic 
■one; c, manifest edema; '/, latent edema. 



edema, and becoming less and less toward the periphery until 

normal pressure is reached. Aside from the quantitative changes 
within the inflamed area, qualitative changes of the constituents of 

the exudate undoubtedly have some important significance. The 
nature of these latter changes is at present tOO obscure to allow of 

any definite statements to be made. 



INFLAMMATION 39 

Clinicians recognize two grades of inflammation— the acute and 
the chronic type. The cardinal symptoms may be readily observed 
in the acute type, i. e., a quick onset manifesting itself within a few 
hours or days; while in the chronic type the slow unfolding of the 
salient features may require weeks and months for their full develop- 
ment with an obscure blending of the various symptoms. Subacute 
inflammation occupies an intermediate position between these two 
grades. 

Whenever living tissue is injured, whether by mechanical, thermal 
or chemical means or by parasites, the system at once tries to pro- 
tect itself against the invading foe by an increased rush of blood 
into the injured area resulting either in a victorious fight, L e., 
complete resolution, or in a surrender to the enemy, i. e., necrosis. 

It is generally assumed that the production of disease does not 
solely depend upon the presence of pathogenic agencies, but that 
the tissues of the body must be in a lowered state of health which 
may lead to a predisposition. The principal predisposing factors 
are hunger, exhaustion, cold and intoxication, although any other 
possibility, which lessens the natural protecting agencies possessed 
by the healthy individual or by any of his organs, may create a 
general or a local lessened resistance. 

Local hyperemia, which is the precursor of acute inflammation, 
results from an increase in the quantity of blood in the injured 
parts. If it is due to an increase in the flow of the blood it is referred 
to as arterial or active hyperemia, while, if resulting from an obstruc- 
tion which retards its outflow it is known as venous or passive 
hyperemia. In active hyperemia the involved area is bright red 
in color, and the temperature is slightly elevated and usually 
accompanied by a marked swelling. Passive hyperemia manifests 
itself by a bluish-red color (cyanosis) of the involved area, with a 
somewhat lessened temperature. The veins are distended and an 
edematous swelling is soon observed, resulting from a transudation 
of the various constituents of the blood. The cardinal features of 
the early stages of inflammation, i. e., hyperemia, are the migration 
of leukocytes, the transudation of serum and the increased activity 
of fixed tissue cells. At present, it seems proved that the thera- 
peutic benefits derived from hyperemia find an explanation in the 
bactericidal action of the blood serum. A detailed discussion of the 
nature of these protective substances— whether they be called 
alexins, antibodies, agglutinins, lysins, protective ferments, opson- 
ins or phagocytes— would have no direct relationship to our subject 
at this point. Let it be recollected, however, that Nature utilizes, 
so far as we know, three important principles of self-protection 
against local infection: Preparation of the path for the transudation 
of the serum, positive chemotaxis and increased activity of cell 
proliferation. 



1(1 DISEASES OF THE DENTAL I'l I.I' 

Quite a number <>t' theories have been promulgated to explain the 
nature of the defensive properties of hyperemia. Buchner claims 
that the increase of the leukocytes and, in consequence, the alexins 
arc the factors. Hamburger believes thai the increased amount of 
carbon dioxid in the blood, as a sequence of the congestive hyper- 
emia, is responsible and these same views are shared by ( hantemesse 
and Lubarsch. Noetzel also favors tliis view, provided it is re- 
stricted to recent exudates, while Metchnikoll', supported bj Ley den, 

Lazarus and others believes that the phagocj tic action of the leuko- 
cytes is the predominating factor. It is claimed that the phagocytes 
break down and thereby liberate active enzymes and ferments 
which combat the invading organisms and digest the degenerated 

broken down cells. We cite these theories and leave them without 
discussion merely emphasizing at this moment the fact that hyper- 
emia is the essential factor which Nature provides in a more or less 
pronounced degree to combat local infection. 

It seems paradoxical to speak of warding off disease by providing 
inflammation. From a therapeutic point of view, however, inflam- 
mation in the past was generally treated by antiphlogistic measures. 
The layman ripens the abscess with a bread and milk poultice or 
some similar irritant. From the earliest time heat, iii the form of 
a cataplasm or fomentation, had been applied 1>\ the medium of 

heated rags, stones, china, etc., and has always ruled supreme in 
the treatment of local infection. Tincture of iodin, the hot-water 
bottle, the alcohol poultice or the Priessnitz bandage, the thera- 
peutic lamp or the electric-light bath and massage accomplish in 
reality the same purpose they produce types of artificial hyperemia. 
Man\ of these remedies act only by counter-irritation, producing a 
secondary inflammation in order to relieve the primary focus of 
irritation. 

Before entering Upon a detailed discussion of the inllaniatun 
disturbances of the dental pulp it will not be amiss to reiterate the 
normal anatomy of this delicate organ as depicted by Professor 

I lopewcll-Smith. 1 

"The* dental pulp is a delicate connective tissue consisting of 
ramified cells imbedded in a slightly fibrous stroma and granular 
transparent basic substance and is plentifully supplied with blood- 
vessels and nerves. It is the soft vascular and sentient organ which 
occupies the central portion of teeth, being naturally bounded on 
all sides by dentin, w Inch thus constitutes its cavity. There are no 
traces of an\ organized lymphatic system in the dental pulp. 
That i-> to say, evidence of the existence of endothelially-lined 
l\ inphatie capillaries or vessels are wanting. Pericellular and inter- 
cellular lymph spaces or tissue -pace- are everywhere apparent, as 

'Hopewell-Smith: The Normal and Pathological Histologj of the Mouth, 
Philadelphia, 1918. 



INFLAMMATION 



41 



rz 




Fig. 14.— Longitudinal section through the cornual region of a young adult molar, 
the dentogenetic zone of which is on the point of calcification. The pulp is in situ. 
Prepared by Hopewell-Smith's process. Stained with Ehrlich's acid hematoxylene. 
Magnified SO times, d. Dentine: p. Pulp tissue in cornu of tooth; d.z. Dentogenetic 
zone; o. Odontoblasts; b.l. Basal layer of Weil; b. Bloodvessels; x. Nerve bundles 
(Hopewell-Smith.) 



42 DISEASES OF THE DENTAL PULP 

also are those around the bloodvessels ;in<l Qerve bundles. The 
pulp i^ saturated with lymph which Is derived From the blood 
plasma, as an exudation from the capillaries. It permeates the 
pulp tissue and exudes into the dentinal tubules around the odonto- 
blast processes. It, however, does not pass into lymphatic vessels, 
and does not leave the pulp by such channels. Yet Schweizer, in 
an elaborate article, claims that by careful injection lie has succeeded 
in demonstrating tufts of lymphatic capillaries in the coronal portion 
of the pulp, which, collecting the lymph of that neighborhood, convey 
their contents into one or two wide lymphatic vessels which issue 
from the apical foramina of the teeth in company with the blood- 
\ essels. The dental pulp is one of those few parts of the body which 
is devoid of any lymphatic system." (Arthur Hopewell-Smith-) 

In a recent publication 1 Kaethe Dewey and Frederick Xoyes, of 
( Ihicago, have made the assertion that they have been able to verify 
Schweizer's statement regarding the presence of lymph vessels in 
the pulp. As yet, their statement has not been generally accepted 
by dental histologists. 

Inflammation of the dental pulp may manifest itself as a destruc- 
tive or productive process. All acute types of inflammation of the 
pulp, i. e.j hyperemia, simple and suppurative pulpitis, are destruc- 
tive in their nature, while the chronic types, ft. 0., ulcerative and 
hyperplastic pulpitis, represent the productive group. Parenchy- 
matous pulpitis, i. 0., the progenitor of the various form- of degen- 
eration, is a non-inflammatory retrogressive metamorphotic process 
and, as a consequence, cannot he classified under this category. 

All acute types of pulpitis are extremely labile in their character. 

i. i ., they change very quickly; within a few hours the alteration 

from an initial obstructive hyperemia into a partial or total Simple 

serous or a suppurative pulpitis may take place. The nature of 

the infection, which in all instances is practically of the same type, 

,i mixed streptomycosis, apparently plays no part in controlling 

the final results. A localized abscess may form in one case, usually 

in a staphylococcus infection, while a widespread phlegmon may 

occur iii another case, as a sequence of a streptOCOCCUS infection. 

The very opposite picture of a destructive, acute pulpitis is 
portrayed l>\ a productive, chronic pulpitis The latter disturbance 
in reality represents thr product of the inflammatory process and it is 
very slow in it.> development, i 0., intensely chronic. The chronic 
types of inflammation oiler excellent opportunities for exhibiting 
the full power of the defensive properties possessed by the pulp 
tissue in it> struggle for existence. The very young and physio- 
all} hyperemic pulp responds bj producing a very vascular 

new -row th of hyperplastic tissue in the open pulp chamber, known 

«, 1917, 1 



INFLAMMATION 



43 



as pulp polypus, while in the mature tooth this same process of 
defence usually results in the formation of pulp nodules and adven- 
titious (secondary) dentin. 



M 



W 



* 



O 



O 



L&- 



•<x 



L: 



A J' 



0; 



Fig. 15. — Transverse section of an adult canine, with the pulp in situ. 1 Prepared 
by Hopewell-Smith's process. Stained with rubine. Magnified 45 times, d. Den- 
tine; p. Pulp tissue proper; oi, 02, 03. Odontoblast layer; a. Artery; v. Vein; m. Mye- 
linic nerve bundle. (Hopewell-Smith.) 



1 The narrowest diameter of the pulp in the section of which Fig. 15 is a photo- 
micrograph measured 1.5 mm.; the widest diameter 3.35 mm. 



1 1 DISEASES OF THE DEN I'M. PI LP 

Parenchymatous pulpitis, in its verj early stages, also assumes 
the character <>t" a chronic inflammation. Soon, however, tin* pulp 
loses all reactive power and From thereon, without even being able 
to respond to an infection, very slowly degenerates. The degenera- 
tion may be a true atrophy, or it maj assume a fatty . a fibroid or a 
calcareous character. Degenerations represents senile metamor- 
photic changes of necrobiotic tissue. 

The anatomic relationship between the dental pulp and its sur- 
rounding hard structure, it being tightly enclosed within an unyield- 
ing wall of dentin, precludes its physical examination. Therefore, 
with one exception, we are unable to recognize the classic sj mptoms 
of acute inflammation. The one exception refers to the sensorial 

manifestation of pain as subjectly experienced by the patient. 

Ordinarily the color of a pulp cannot be observed except in trau- 
matic or pathologic exposures. When the exposure is sufficiently 
large a bluish-red, pulsating tissue slightly protruding from the 
cavity may be seen. Whether or not the temperature of an inflamed 
pulp is higher than normal cannot he adequately ascertained, a- 
our physical apparatus the thermometer is too cumbersome an 
instrument to lend itself with any degree of satisfaction to the 
caloric inspection of so minute an organ as the dental pulp. 
Impaired function of the tooth as a sequence of pulpitis does not 
occur; the tactile sense of the tooth is restricted to it- investing 
membrane, i. e. f the pericementum. Consequently, the only symp- 
tom left for consideration is the manifested pain. Pain is always 
present in the genuine types of acute inflammation. It is tin- result 
of pressure exerted by the exudate on terminal nerve filament- and 

additional irritation produced by toxins, acids, enzymes, etc It 

proportionally increases with the acceleration of the exudate. The 

severest type of pain is manifested in suppurative pulpitis. It- 
character is less severe in chronic types and it is totally absent in 
true degeneration, as in this condition there is no exudate. Fortu- 
nately, the subjective exhibition of pain from an inflamed pulp is SO 
very characteristic in its subtle differentiations that by its guidance 
we are able to arrive at a fairly accurate differential diagnosis. 

If we compare the peculiar anatomic structure of the dental pulp 

with other soft tissues of the body we arc at once forcibly impressed 

with the enormous difficulties which we are apt to encounter in our 

humble efforts to applj conservative treatment. Four outstanding 
negative factors are at once recognizable. A- stated 1 the pulp 
is encased in a hard, unyielding capsule of dentin; 2) no lymphatics 
are present within its mature structure; 3 it is impossible to estab- 
lish efficient drainage; and 1 it is difficult to gain ready access to 
the diseased organ for the purpose of applying remedial measures. 
The extravasated serum as it occurs in the early stages of inflam- 
mation cannot well be accommodated within it- own body, i. >.. 



INFLAMMATION 45 

the pulp cannot swell and, therefore, the serum quickly spreads over 
the entire organ. By this increased internal pressure a partial 
pulpitis very rapidly changes into a total pulpitis, with the in- 
crease of the exudate, incidentally containing acids, toxins and 
ferments, augmented pressure and irritation is exerted upon the 
nerve filaments which, in consequence, respond with a progressive 
exacerbation of pain. This phenomenon is peculiar to an inflamed 
pulp; it is the reverse of what ordinarily takes place in other soft 
tissues. 

A further important factor which markedly lessens the chances 
of resolution in an inflamed pulp consists, as stated, in a total 
alienee of lymph vessels in the mature organ. Ordinarily, the 
resorption of the exudate occurs primarily through the lymphatics. 
If the exudate is not removed the increased internal pressure 
changes the primary obstructive hyperemia into a more or less 
complete stasis, i. e., stagnation of nutrition and circulation. As 
the dental pulp cannot establish a collateral circulation, at least not 
in the single-rooted teeth, the danger arising from an interference 
with the nicely balanced blood-pressure of the healthy organ is of 
enormous significance in regard to its future well-being. A dog- 
matic biologic law asserts that at no time should the blood current 
be interrupted; complete persistent stasis always signified death 
of the involved tissue. By comparing the very small foramina of a 
fully developed human tooth with the relatively large bulk of its 
pulp, it is surprising that a resolution of an inflamed pulp ever occurs. 
If, accidentally, the causative factor of the inflammation of a pulp 
is of an infectious nature, a collection of pus results which localizes 
itself into an abscess, but more often on account of the labile nature 
of the involved tissue it readily spreads over the entire pulp. Asep- 
tic inflammation due to mechanical causes or to chemical substances 
other than those derived from living organisms may also occur. 
However, even if primarily no bacteria may have been present, as 
a rule, sooner or later they make their appearance and the sequences 
of infection are added to the original insult. 

Abscess formation is by no means always the sequence of an 
inflammatory process. Its termination rests with the degree of the 
produced inflammatory changes and the quantitative damage 
involved in the destructive process. The simplest outcome is 
recovery by resolution. If the disturbance has been of a mild 
character the exudate is taken up by the lymphocytes and is 
returned to the circulation while the damaged cells are removed by 
the phagocytes. Should there be present a preponderance of 
escaped polynuclear leukocytes the exudate is referred to as pus. 
The physical nature of the pus is largely dependent on the biologic 
peculiarities of the different bacteria and their activities upon the 
surrounding structures. In the ordinary soft tissues the newly 



16 DISE iSES OF THE DEh I'M. n LP 

formed abscess terminates the local process, i. e. $ with its natural 
rupture or through an incision the confined pus Is released, drainage 
is established and immediate reorganization of the involved area is 
instituted. In the dental pulp, unfortunately, suitable drainage 
cannot be established, partially on account of the minuteness of 
the organ and partially on account of the inaccessibility to the focus 
of infection. The late W. D. Miller pictured the difficulties of 
treating an inflamed pulp by citing the following unique compari- 
son. "If we attempted to treat an inflamed finger-tip through a 
small hole drilled into a thimble placed over this tip we should find 
it wrought with many difficulties and, most likely, with little hope 
of success as compared with the treatment of the same condition 

without the thimble." 

Tul]) tissue, in many respects, is analogous to hone marrow, and 
shares with it the very labile nature of this structure. As it possesses 
only a Aery low degree of resistance and very little power of reorgani- 
zation, any pronounced disturbance of its equilibrium i- almost 
certain to cause its death. Even the application of such sedative 
or antiseptic drugs which, relatively, are usually tolerated by other 
tissues, have proved to be destructive to this delicate organ. 

After the subsidence of the inflammatory process in the ordinary 
tissues, organization and repair are instituted at once. ( rranulation 
tissue is formed, which acts as a strong barrier to absorption and 
reinfection. Healing of the wound takes place by first or second 
intention. Both processes are analogous except in the matter of 
quality formation. Healing by first intention will always occur iii 
a non-infected wound, while in the process of repair by second inten- 
tion a large amount of granulation tissue i- formed. Profuse secre- 
tion keeps the walls of the wound clean and active hyperemia of the 

involved area furnishes the necessary nutriment for the increased 

cellular activity. Granulations spring from the bottom of the 
cavity to replace the lost tissue and epithelium, if present, quickly 
covers it^ surface. In the injured dental pulp resolution is very 
rarely observed. Pulp tissue, as stated, consists primarily of 
embryonic connective tissue, poor in fibers, and it does not contain 
epithelium. The highly specialized connective tissue of the dental 
pulp possesses practically no ability of reorganization and, con- 
sequently, repair by first or second intention, except in a few 

isolated instances is practically impossible. In tin 1 adult tooth 
death of its pulp is the usual sequence of an inflammation. 

The loftiest aim of applied therapeutics within the province of 
operative dentistry should find it- sublime expression in the con- 
servative treatment of the dental pulp. It is to be regretted that 
the realization of this ideal, for the present at least, is restricted to 

\er\ limited bound-. Theoretically, from the viewpoint of experi- 
mental surgery, restoration of the Function and vital energy of the 



IN FLA MM A TION 47 

diseased pulp should offer no difficulties; clinical experience, how- 
ever, does not bear out this statement. 

Basing his judgment upon the above discussed difficulties as they 
present themselves clinically and in conformity with the general 
consensus of opinion of the majority of practitioners, the writer 
frankly admits that the prognosis of an inflamed pulp is, in most 
instances, unfavorable. Dogmatically, it may be asserted that 
a severely inflamed mature pulp is a lost organ and its removal is an 
imperative necessity for the future welfare of the respective tooth 
and the individual as a whole. The author does not wish to impress 
the reader, however, that every case of pulp disturbance ad hoc is 
hopeless and calls for immediate destruction of this organ; he is 
convinced that certain types of obstructive hyperemia and possibly 
the very earliest states of acute pulpitis in a young growing tooth 
are amenable to conservative treatment, and, as a matter of fact, 
such treated pulps occasionally do respond by resolution. No 
rule of thumb can be laid down; the judgment of the operator has 
to decide each individual case in accordance with a carefully made 
diagnosis and with due consideration of all circumstances. While 
it is true that the chances of recovery of a disturbed young growing 
pulp have much in their favor, the same chances in an adult pulp 
—cceteris paribus— are always extremely poor. In the latter cases 
it may be dogmatically stated that the only absolute safe treatment 
of a severely inflamed adult pulp is its destruction and removal. 

The ruthless destruction of the dental pulp in every given case, 
as advocated by one group of practitioners, is equally as futile as 
the extreme conservatism displayed by another group. Here, as 
in everything else pertaining to the practice of the medical arts, 
sound clinical reasoning based upon an intimate knowledge of 
pathologic anatomy should be the guiding post. 

The question may be rightly asked at this moment : What value 
possess the living pulp for the future preservation of the tooth? 
As an indisputable clinical fact it must be admitted that a pulpless 
tooth has lost much of its resistance to secondary carious processes. 
Secondly, the crown of a pulpless tooth containing a necrosed pulp 
is liable to become discolored and, thirdly, a pulpless tooth, as a point 
of minor resistance, offers suitable chances for the future develop- 
ment of periapical disturbances. Improved technical methods in 
the bleaching of discolored teeth have largely eliminated the second 
objection. The last factor, especially, has, within recent years, 
given rise to much unsound speculation. Zealous advocates of 
wholesale extractions have culminated their erratic views by employ- 
ing such catch phrases as : The pulpless tooth must be eradicated 
from the human economy, which is equally as hazardous a proposi- 
tion as the assertation of the extreme conservatives who pretend 
to save every pulpless tooth. While there are numerous cases of 



18 



DISEASES OF THE DEh TAL I'l LP 



infected pulpless teeth retained in the mouth whicfa const it ute a 

distincl mena< e to the general health of the individual, and which 
as a consequence should Invariably be removed, there also exists the 
indisputable clinical fact that the greatest majority of pulpless 
teeth by the presenl improved methods of treatment of infected 
root canals may lie restored to health. 








16, Exposed pulp protecting itself against infection, a, Secondary dentin; 
/', round cell infiltration; c, denticle; '/, chronic pulpitis. (Will 

Evidence has been Furnished by Tomes, Gysi, Williger, Roemer, 
[toy, Wachtl and others that on verj rare occasions a ])ulj) may 
possess the power of protecting it-elf against an arising infection. 
Chronic types of pulpitis, i. >.. hypertrophy and ulceration are 
examples of the gallant struggle <>f an infected pulp against the 
invading fee. However, occurrences of this type are extremely 
rare and attempts of conservative treatment based upon such 
accidental possibilities are not to he encouraged, except in a few 
isolated instances in which the general conditions seem to justify 
t he pnx edure. 



CHAPTER III. 

ETIOLOGY OF DISEASES OF THE DENTAL PULP. 

When a patient suffering with pain in a tooth which contains an 
aching pulp appeals to the dental practitioner for treatment, it is 
the paramount duty of the latter to ascertain whether the diseased 
pulp is amenable to conservative treatment, or whether it should 
be destroyed. From a clinical point of view it is imperative to 
ascertain, if possible, the morbific cause of the disease, i. e., its 
etiology. The early removal of the cause and the prevention of its 
return as instituted by the physician frequently produces a "cure," 
while the return of the pathologically altered tissue to normal 
physiologic function is accomplished by Nature. In the words of 
Celsus this axiom is expressed as natura sanat, medians curat. 



SCHEMATIC OUTLINE OF CAUSES OF PULPITIS. 



Pulpitis 



Primary causes 



Causes of a 

mechanical nature 



Causes of a 

chemical nature 



Traumatism, abrasion, calcare- 
ous deposits within the pulp, 
fillings (direct and indirect ) 
and retention pits, correction 
of irregularities, separation of 
the teeth, pressure from sub- 
stances wedged into cavities, 
etc. 

Caustics, protoplasm poisons, 
products of bacterial metab- 
[ olism, etc. 



Secondary causes 



Causes of a thermal or electric nature. 



k Causes of a parasitic or mixed nature. 

/Causes originating in the pericementum. 
\ Causes as a sequence of general diseases. 



The causes of diseases of the dental pulp are identical with those 
which are responsible for the production of pathologic disturbances 
in other tissues of the body, and, in accordance with the accepted 
standards of the practice of the medical art, may be referred to as 
being primary or secondary in their nature. The causes may be 
mechanical, chemical, thermal, electric or parasitic in their nature. 
All of these disturbances produce local manifestations. The 
primary causes, as their name implies, attack the pulp directly, 
such as an infection from a carious defect; while the secondary 
4 



50 



DISEASES OF THE hi:\ TAL IT LI' 



causes -elect ;m indirect route. as those arising from a pericementitis 
or an osteitis. 

The vast majority of the causes which are responsible for patho- 
logic disturbances of the dental pulp find their origin in a direct or 
indirect association with the infective processes of the hard struct- 
ures of the tooth, i. e. t dental caries as a sequence of a streptomj cosis 
of a mixed type. The very same organisms which are closely asso- 
ciated with the carious process are always predominant in an 
infected dental pulp. 

To facilitate the ready classification of the etiologic factor- of 
the disease of the dental pulp from a clinical point of view, the 
schematic outline on p. 49, as suggested by the late \Y. I). Miller, 
will he found to he of service. 



I i... 




Typical Bporl accidenl 



icture <>f upper firsl i i i<i-< >i-. Mayrhofer.) 



Causes of a Mechanical Nature. Traumatic disturbances of the 

pulp are manifold in their character and are commonly met with 

in clinical practice. Such accidents as a fall, a blow, or being hit 
by some solid object, are of frequent occurrence. Children and 

those adults who indulge in the various types of sports are prone 

to he injured about the teeth. On account of their prominence, 

the upper anterior incisors suffer more often than the other teeth. 
Sport accidents, Mich as ;i fall in skating, etc.. Usually cause t\ pica! 

fractures of the upper central-. Accidents, such as the breaking 
of a tooth during extraction, are also frequent occurrence-. During 
the excavation of a carious defect the pulp is often accidentally 
exposed. A Fracture of the tooth crown ma\ directly expose the 

pulp, "i- it nia\ OCCUr in SUch close pro\iniit\ to this organ that it 

becomes advisable to destroy it at once. A careful examination of 
the broken surface with a magnifying glass and a sterile explorer is 
of great service in discovering a possihle minute opening. 



ETIOLOGY OF DISEASES OF THE DENTAL PULP 



51 



An exposure of the pulp must always be looked upon clinically 
as an infection, and it should be treated accordingly. If the tooth, 
as a whole, is loosened, an effort should be made to retain it, if 
possible, in its normal position by ligatures, splints, etc. After the 
tooth has again become firm it may be tested by the electric current 
to ascertain the state of its pulp. 




Fig. 18. — Abrasionof anterior teeth, with loss of posterior occlusion. (W. A. Capon.) 

Mechanical destruction of tooth structure through abrasion is 
primarily observed in the aged. In case of loss of the posterior 
teeth, the anterior teeth are often called upon to bear the entire 
force of mastication, and as a consequence abrasion of these teeth 
at their incisal edges takes place. Irritation of the exposed dentin 




Fig. 19. — Artificial abrasion produced by brushing with a much-used English 
tooth paste with motor brush for eighteen hours. Remains of gold filling in first 
bicuspid. (Miller.) 

causes a renewed physiologic activity of the pulp which results in 
the deposition of adventitious dentin in the pulp chamber. Fre- 
quently this deposition is insufficient to keep pace with the rapid 
process of abrasion, and in due time the pulp becomes involved. 
Certain occupations, such as sand-blowing, glass-cutting, tool- 



52 DISB iSES OF THE DES TAL l'( LP 

grinding, etc., in which the atmosphere is charged with abrasive 
dust, are prone to cause marked wasting of tooth structure. Skulls 
of Bedouins, as the nomadic tribes inhabiting the sand-saturated 
atmosphere of the Sahara desert, exhibit pronounced tooth abrasion. 
The " pipe-stem hole" of the clay pipe smoker and the " blow bole" 
of the glassblower are typical examples of localized abrasion. 
Seamstresses, who are in the habit of biting threads, occasionally 
also exhibit localize. I abrasion of the first or second incisors, although 
more often periapical disturbances are observed in these cases from 
the direct force applied to the long axis of the tooth. 

A peculiar type of progressive destruction of tooth structure is 
known a^ erosion or, on account of the typical style of cavity pro- 
duced, as "cuneiform defect-." Comparatively little is known of 
this somewhat common condition. Usually, the typical cavity pro- 
duced by erosion presents ;i sharp-edged, smooth, highly polished 
groove at the necks of the teeth, running transversely to their long 
axes. Principally the labial and buccal surfaces arc involved. 




I (escribed as erosion. 1 tarby.) 



In the acute stages irritation of the exposed dentin surfaces is usually 

painfully noti< ed by the patient, while in chronic \\ pes of erosion a 
marked absence of pain is to be observed. 

( 'alcareous deposits within the root canal, either as advantitlOUS 

dentin or in the form of pulp nodules, are of very common occurrence 

indeed. Occasionally they produce obscure types of Idiopathic 
pulpitis which may baffle the most expert diagnostician. 
The irritation produced in preparing a deep-seated cavity for the 

reception of ;i filling, and retention pit- which arc located within 

close proximity of the pulp, are frequently sources of hyperemia of 
this vascular organ. In these cases the additional thermal changes 
of the metallic plug (metals being good conductors of temperature 
must be taken into consideration. Intense force employed in 
mallet ing i:<>ld foil fillings indirectly has caused the death of many 
pulps. 

The n.M rapid movement of a tooth for the purpose of correcting 
an irregularity . or the application of quick ami intense Force in the 



ETIOLOGY OF DISEASES OF THE DENTAL PULP 53 

mechanical separation of teeth, may occasionally produce severe 
types of hyperemia or even death of the pulp by strangulation. 
The use of rubber strips for separating teeth, which was so fre- 
quently employed for such purposes in former years, is especially 
prone to cause pain about a tooth. In removing the rubber dam, 
small circles may be torn from it and remain under the free margin 
of the gum, and when left unobserved the resilience of the rubber 
causes these rubber circles to move upward, impinging upon the 
peridental membrane, and pericementitis and subsequent pulpitis 
may be the result. Direct pressure from substances forced into a 
deep cavity, in which the pulp is exposed or covered by a frail layer 
of dentin, such as taking an impression with modeling compound, 
or food crowded into it, may cause pulpitis. 

Causes of a Chemical Nature.— Chemical irritants, such as acids, 
sweets, protoplasm poisons and metabolic products of bacteria are 
common etiologic factors of pulpitis. It is a well-known clinical 
observation that a pulp may readily die under a deep-seated cement 
filling; especially is this accident liable to occur under a silicate 
filling. Various theories have been promulgated to explain the 
nature of this accident. The most reasonable explanation is based 
upon the fact that the cement fluid, which is primarily a concen- 
trated solution of orthophosphoric acid, penetrates through the 
dentin and in due time kills the pulp. Phosphoric acid does not 
coagulate albumen, hence its slow penetration by osmosis through 
dentinal tubules, which are filled with protoplasm in the form of 
Tomes' fibers, will occur and destroy the underlying pulp by its 
caustic action. Apparently the respective thickness of the layer 
of dentin is of little consequence except in the matter of time. In 
the oxyphosphate cements the action of the acid is largely nullified 
by its combination with the zinc oxid, while in the silicate cement, 
in which the fluid is usually present as an acid aluminum phosphate, 
the acid remains "free" for a prolonged period, and hence its 
deleterious influence upon the pulp is manifested in due time. 
Experimental proof of this assertion may be readily demonstrated 
in the experimental laboratory. By protecting the walls of the 
prepared cavity with a suitable insulator in the form of a hard 
varnish, the danger of penetration of the acid is materially lessened. 

Sweets, by their hygroscopic nature, are usually only temporary 
irritants, while certain protoplasm poisons, especially arsenic tri- 
oxid may be intentionally applied to destroy the pulp. Impure 
cement powders containing traces of soluble arsenical compounds 
are known to have caused death of the pulp. Recent improve- 
ments in the manufacture of these cement powders have eliminated 
the presence of arsenical impurities. If arsenic is present in any 
one of the various filling materials it will assert its most powerful 
deleterious effects very promptly. Arsenic present in almost infini- 



5 1 DISE iSl - OF THE UBh TAL PULP 

tesimalrj small quantities, i. e. t I part to 1,000,000 parts of the 
filling compound, is known i<> have killed the pulp. Acid fumes, 
especially those of inorganic acids (hydrochloric acid, etc.) arc the 
greatest enemies of tooth structure. The} dissolve tooth substance 
and thereby expose the pulp. Among the organic acids, the damage 
done 1)\ tartaric acid in the so-called "grape-cure" should be 
mentioned. 

I'lilp irritation from thermal changes, as stated above, is very com- 
mon. This i- especially true in regard to deep-seated metallic 
fillings, as metals are excellent conductors of heat and cold. Violent 
thermal shocks resulting from the injudicious use of refrigerant 
local anesthetics, i. e., ethyl chlorid, etc., maj produce pronounced 
hyperemia or even strangulation (death) of the pulp with a break- 
ing down of the corpuscular elements of the blood and infiltration 
of the laked hemoglobin into the tubular structure of the dentin. 
Permanent injury and, in many instances, death of the dental 
pulp resulting from heat evolved during the "setting" of dental 
cements within a tooth cavity is frequently observed. A few 
explanatory remarks are necessary for the read} comprehension of 
this interesting phenomenon. Living protoplasm is killed by heat 
and the process is not reversible. In warm-blooded animals 1 1-*>° F. 

1") ( . i- generally considered a temperature at which death occurs 
in a very few minutes. However, even a temperature of K> ( .>° F. 

13 < • may l>e considered dangerous; of course, it will take a 
longer time to bring about fatal results. At present, it i- generally 

held that death under these conditions is due to an irreversible 
heat coagulation of the proteins. The changes in the blood circu- 
lation i- most pronounced. There is a distinct -ta>is to be observed 
in the superficial veins with hemolysis and the first indication- of 
necrosis within the superficial tissue la\ ers. Most probably , poisons 

arc formed as a result of the hum which are particularly toxic to 

the nervous tissue. The chief cause of death from hum- i- not 
to he attributed to the Mood changes alone, but theory is in favor 
of the development of toxic substances. "Heath occur- because 

the vital machinery ha- heen broken down." 

During the process of "setting" of certain dental cements rather 
high temperatures are observed. By employing an automatically 
la ted thermometer, the writer observed temperature ranges from 
quantities of freshly mixed cement- suitable for an ordinary filling, 
which registered from 95 F. 35 C. to 145.5 F. 63 C. during 
the period of "setting" la-tinu r from two to five minutes. Cements 
of the oxyphosphate type are fairly good conductor- of heat; if we take 
the conductivity of gold a- a standard, i. >.. LOO, cement- register 
at about 55 to 60. 1 dentin rank- about equal with the cement-. 

From the above discussion it maj be assumed that the heat 
evolved during "setting" of certain cements, combined with the 



ETIOLOGY OF DISEASES OF THE DENTAL PULP 55 

presence of "free" phosphoric acid, when placed in deep-seated 
cavities is quite sufficient to permanently injure and, in many 
instances, kill the dental pulp. The numerous deaths of pulps 
under cement fillings as observed in clinical practice are sufficient 
evidence to verify this assumption. 

Shocks from electric disturbances within the oral cavity, which 
manifest themselves in a painful response of the irritated pulp, are 
quite frequently observed. In cases in which electro-positive and 
electro-negative metals are simultaneously employed within close 
proximity as filling materials or as prosthetic appliances, the 
presence of saliva completes the electric circuit. Gold is an electro- 
negative metal, while aluminum or amalgam with its predominance 
of mercury are on the positive side. The interposed saliva acts 
as an electrolyte, and through ionization a voltaic current is com- 
pleted which manifests itself in a migration of the positive ions to 
the negative pole, and thereby a measurable amount of electricity 
is evolved. Incidentally through the process of ionization of 
saliva, which always contains sodium chlorid, hydrochloric acid 
is formed at the positive pole. If, for instance, a gold clasp sup- 
porting a denture is placed about a tooth containing a large amalgam 
filling, the acid set free at the point of contact dissolves the tooth 
structure, and from the electro-motive force created the gold band 
may break. 

An interesting observation directly bearing upon electric dis- 
turbances of the pulp is reported by Prof. Harris. 1 He states that: 
"In the summer of 1912 I had a lower molar tooth filled with a 
temporary stopping, consisting of an amalgam of at least three 
metals, silver, mercury and tin. Within a half an hour of having 
this inserted I noticed that each time I clenched the jaws at all 
forcibly there appeared a bright flash of light in the left eye; all 
through the rest of the day flashes of light, getting fainter and 
fainter, kept recurring. I noticed that the tooth in the upper jaw 
which touched the amalgam in the lower was gold-capped. The 
light experienced was a canary yellow and more like the sensation 
of a vivid lightning flash (forked lightning) than of any mere 
luminosity or diffusion of light. So vivid were these subjective 
flashes that my first thought was that there had been lightning, but 
on the day in question there was no lightning, thunder or rain. 
Dr. Frank Woodbury kindly told me that he had known of currents 
caused in this way being sufficiently intense to give pain in the 
upper gold-covered tooth when that tooth had an unduly sensitive 
ner\ r e. I, therefore, suggest that an electric current thus produced 
was conducted through the bones and tissues of the head and, 
encountering the retina en route, stimulated it to give rise to the 

1 Harris, D. Fraser: Transactions of the Nova Scotian Institute of Science, vol. 
14, pp. 47. 



DISS [81 & OF nil-: DBS TAL PULP 

subjective sensations of light. The possibility of stimulating the 

retina tn situ by electric current was discovered by Ritter In l s| »"; 
a constant current passed either transversely across the head in 
the temporal regions or from the eyelid to the neck will, both at 
make and break, stimulate the retina causing Bashes of light to be 
perceived. Ij renewed my acquaintance with these effects by 
passing the constant current from one dry cell through the i 
transversely across the head; at the make and break the flashes 
due to this current were less vh id than the flashes due to the tooth 
current. On using two dry cells, I obtained flashes closely resemb- 
ling those from the tooth current. I am assured that the current 
from two dry cells would be painful to the inflamed nerve of a 

tooth." 

Causes of a Parasitic Nature. Causes of a parasitic nature pro- 
ducing pulpitis are more often met with than any other known 
disturbance. Bacterial invasion of the dental pulp is probably 

always due to a mixed infection in which the streptococci are 

predominating over other organisms. Cognizance must be taken 
of the chemical metabolic products concomitant with the bacterial 
invasion, i. e. t acids, ptomains, toxins, etc., and the simultaneous 

action of mechanical and thermal disturbances. 

The bacterial invasion of the pulp occurs in the great majority 
of cases directly from the carious process or indirectly by way of 
the pericementum near the \'vvv margin of the gum tissues. lnf< c- 
tious border-line diseases, which involve the accessory cavities of 
the nose, and those of the tissues surrounding the teeth, are fre- 
quently responsible for the manifestation of secondary pulpitis. 
Invasion of the pulp by bacteria from hematogenous causes via the 
circulation are comparatively seldom observed. 

Secondary Pulpitis, as a sequence of a local or a general di» 
is by no means a rare occurrence. In the majority of cases the 
underlying disturbance is an infection, although general diseases 
of a non-infectious type, such as leukemia, locomotor ataxia, 
anemia, chlorosis or increased intradental blood-pressure, etc., may 
he the exciting factors. Of the infectious diseases, acute nasal 

catarrh involving the antrum i^ probably more often concerned 

with secondary or idiopathic pulpitis than with any other border- 
line disturbances, although other infections of a general character 
affecting the mucous lining of the nose or the circulation as a whole. 
such as influenza, pneumonia, scarlet fever, measles, malaria, etc. 
must !>•• mentioned. Infectious disturbances of the temporo- 
maxillary joint, i, e. s acute mandibular arthritis, may bring about 
ondary pulpitis in the teeth of tin lower jaw. 



CHAPTER IV. 
CLASSIFICATION OF DISEASES OF THE DENTAL PULP. 

Concerning a classification of the various diseases of the dental 
pulp— nosology— quite a confusion exists in our current literature, 
and unfortunately, even in many of our text-books a detailed dis- 
cussion of this interesting subject is often avoided. Not alone is 
this apparent laxity of clinical inquiry appalling to the searching 
student, but he is also confronted with a gross neglect of correct 
pathologic terminology. Hyperemia, inflammation and gangrene 
are the usual routine terms selected to designate the bulk of the 
various types of pulp disorders. Hyperemia has been called irri- 
tation of the pulp, which in itself is a misnomer, as irritation is the 
cause and not the disease. This is equally true in referring to 
inflammation as a disease. The collective term "pulpitis" is fre- 
quently employed to designate generically all states of inflammation 
of the pulp. 

Again, gangrene, a term which is utilized to cover the various 
phases of dead pulp tissue, is referred to as a disease, while in reality 
it is the sequence of necrosis, i. e., the necrotic pulp is acted upon 
by specific organisms, which results in gangrene. Obviously, a 
dead pulp cannot be " treated," as it is no longer "diseased." 

From a purely pathologic point of view, Arkoevy 1 has probably 
presented, so far as known, the most subtle division of pulp diseases. 
For clinical purposes, however, this division is too complicated. 

1 Classification of Diseases of the Pulp (Arkcevy). 

I. Pulpitis acuta. 

1. Pulpitis acuta septica seu superficialis. 

2. Pulpitis acuta partialis. 

3. Pulpitis acuta totalis. 

4. Pulpitis acuta partialis purulenta. 

5. Pulpitis acuta traumatica. 
II. Pulpitis chronica. 

1. Pulpitis chronica parenchymatosa. 

2. Pulpitis chronica totalis purulenta. 

3. A. Pulpitis chronica hypertrophica granulomatosa. 
B. Pulpitis chronica hypertrophica sarcomatosa. 

4. Pulpitis chronica idiopathica seu concrementalis. 

5. Gangrsena pulpae totalis. 

6. Pulpitis chronica idiopathica seu concrementalis. 
III. 1. Atrophia pulpae simplex. 

2. Atrophia pulp® sclerotica. 

3. Atrophia pulpae reticularis. 

4. Dissolutio pulpae absoluta. 



58 DISEASES OF THE DENTAL PI LP 

Man} other classifications have been brought forward, among 
which we maj cite the classic schemes of Rothmann and of Black 
and those of John Tomes, Wedl, Adolf Witzel, Abbott, Miller, 
Boedecker, Burchard, Roemer, Walkhoff, Hopewell-Smith, Fischer, 
Colyer, Kantonw icz and others. To construe! b scheme of classifi- 
cation of diseases of the dental j >n 1 j > which answers all purposes 
equally well is quite difficult, and Is very largely a matter of personal 
equation. However, there arc certain unalterable pathologic facts 
which must be observed as being fundamentally essential for a 
suitable division. Ordinarily we refer to a sound, healthy pulp as 
a normal pulp; this very term, however, needs some further ampli- 
fication. The tooth pulp .should he looked upon as a transitory 
organ. Normally, with the completion of the tooth its function is 
accomplished, and from that period retrogressive changes take place 
within its own tissue which may under suitable conditions lead to 
complete atroph\ or other types of degeneration. At some other 
period, however, its activity as a constructive organ may be called 
upon after calcification of the tooth Is accomplished. As the result 
of some pronounced type of stimulation it ma\ deposit adventitious 
dentin and pulp nodules for thi' purpose of protecting its own 
integrity, or some other factors of overstimulation of the exposed 
pulp may lead to the formation of a hyperplastic growth, i t. % 
pulp polypus. As it is a very vascular organ, any disturbance of 
its integrity will manifest itself in the typical reaction of a tissue 
to an injury inflammation. 
The primary manifestations of the inflammatory process always 

occur at the place of entry of the disturbance, i. e., usually in the 

corona] portion of the pulp. As a sequence, a partial acute simple 
pulpitis is the result. The character of the severity of the infection 
determines the rapidity of its progress. Within a comparatively 
short space of time, usually within a few hours, or rarely days, total 
inflammation of the pulp quickly follows the initial disturbance. 

To differentiate clinically between a partial and a total acute 
pulpitis which, incidentally, i> merely a quantitative and not a 
qualitative manifestation of the inflammatory process is very 
difficult, if not impossible. From the viewpoint of the clinical 
pathologist there is no valid reason for such a subtle diagnosis, as 
the treatment of both grades is virtually the same. 'The progres- 
sive increase of the acute infection leads tO the formation of a 

localized collection of pus, i. < .. an abscess, or to a general suppura- 
tive infiltration between the spaces of the connect i\e-t issue cells, 

i. i., a phlegmon. Again a partial, however in most instances a 
total suppurative, pulpitis is the sequence, which for the ab 
stated reasons need not be diagnosed separately. 

Most acute types of pulpitis terminate in a surprisingly short 
tune in necrosis or gangrene. Under certain conditions, how< 



CLASSIFICATION OF DISEASES OF THE DENIAL PULP 59 

the acute form may assume a chronic stage. The prerequisites 
for the change from an acute into a chronic pulpitis are: a pulp 
possessed of a high degree of vitality and free drainage of the formed 
exudate, i. c, an open pulp chamber. The various stages and final 
results of chronic pulpitis are manifold; usually two types are 
diagnosed, namely, ulcerative pulpitis and hyperplastic pulpitis. 
The former type is most predominant in the neglected mouths of 
children. An intermediate subacute grade of chronic inflammation 
occasionally occurs, and is known as parenchymatous pulpitis. In 
most instances the latter is the predecessor of the numerous types 
of degeneration of the pulp. 

As has been stated above, inflammation of the dental pulp may 
manifest itself as a destructive or a productive process. All acute 
types of pulpitis are destructive in their nature, while the chronic 
types represent the productive, often referred to as the "construc- 
tive" group. This classification, which is based upon manifested 
histopathologic symptoms, is still frequently employed by clinicians, 
and may be depicted as follows: 

A. Acute destructive pulpitis (the pulp usually is not exposed): 

1. Acute simple pulpitis. 

2. Acute suppurative pulpitis. 

B. Chronic productive pulpitis (the pulp usually is exposed): 

1 . ( hronic ulcerative pulpitis. 

2. Chronic hyperplastic pulpitis. 

It will be observed that the above classification does not take 
any special cognizance of such important clinical manifestations as 
hypersensitive dentin, the exposed healthy pulp, hyperemia of the 
pulp, degeneration of the pulp, secondary pulpitis and necrosis 
and gangrene. 

Hypersensitive dentin, when viewed as a clinical entity, may be 
designated as a state in which the exposed dentin of a vital tooth 
is painfully responsive to any type of irritation. The physiologic 
normal dentin has no sensation; by virtue of the innumerable pro- 
toplasmic fibers, which traverse it from the pulp cavity to the 
periphery tactile impressions, thermal changes and chemical or 
electric irritations are transferred to the anatomic threshhold of 
sensation, i. e., the nerve filaments distributed at the surface of 
the pulp and which now react in varying degrees. The response 
to these various types of irritants is merely an expression of magni- 
fied impulses and consequently, in its final analysis, hyperesthesia 
of dentin denotes an irritated pulp. From the viewpoint of the 
clinical practitioner, therefore, the treatment of this type of pulp 
irritation necessitates a detailed discussion. 

The exposed healthy pulp in reality should not be included in 
the discussion of diseases of the dental pulp proper. However, as 
the exposed pulp, from a clinical point of view, must always be 



60 VISE iSES 01 THE DENTAL PULP 

looked upon ;i^ an infected tissue, and one which a-> a consequence 
requires treatment, ;i discussion of the procedure of protecting the 
exposed pulp Is imperative, and therefore its insertion at the begin- 
ning of our grouping of the pulp diseases proper seems to be justifi- 
able. 

1 1\ peremia of the dental pulp portrays a clinical manifestation of 
pulp disturbance which in actual practice is probably more often 
met with than anj other type of disorders of this organ. It- correct 
diagnosis an<l the subsequent method of treatment is of the utmost 

interest to the clinical practitioner. 

Clinically, degenerations of the pulp do not form a group of 
recognizable diseases, as they cannot be diagnosed in situ, hence 
their discussion is of less interest to the practitioner. Generically, 
they constitute an important part of special pathology, and are 
referred to in our grouping only from the viewpoint of the genera] 
practitioner in order to complete the chain of clinical pathology. 

Secondary or idiopathic pulpitis usually manifests itself as 
hyperemia, or, in rare instances, as any one of the inflammatory 

types of pulp disorders, or as necrosis. As its name implies, its 

secondary manifestations arc always the sequence of some primary 
diseases. Clinically, these border-line diseases play a most import- 
ant role in the routine Work of the general practitioner, hence they 
are entitled to a special consideration. 

Death of the pulp, i. e. s necrosis and its sequence, gangrene, as 
stated above, must not be classified a^ "disease." Clinically, its 
frequent occurrence and its many sequels are of vital importance 
to the practitioner, consequently the removal of the dead pulp 
tissue and the subsequent treatment of the pulpless tooth need to 
be discussed in detail. 

In the following simplified classification it has been our aim to 
Formulate a grouping of the disorders of the dental pulp from the 
viewpoint of the clinical practitioner. The specific symptomatology 
of each existing pathologic condition has been selected to serve as 
the guiding mentor SO as to be able to portray the respective ail- 
ment as a clinical entity. Its object is to present a working basis for 

the ultima ratio of all clinical procedure's, namely, the application 

of rational therapeutic measures, in the broadest sense of the term, 
for the purpose of relieving, preventing or favorably modifying the 
evolution of diseases of the dental pulp. 



Classifk \mm\ of Disorders oi the Dental Pulp. 

I . Types of irritation: 

1 . 1 1\ persensitive dentin. 

2. 'The exposed healthy pulp. 

3. Hyperemia. 



CLASSIFICATION OF DISEASES OF THE DENTAL PULP 61 

II. Types of inflammation (Destructive pulpitis): 

1. Acute simple pulpitis. 

2. Acute suppurative pulpitis. 

3. Secondary pulpitis. 

III. Sequences of inflammation (Productive pulpitis): 

1. Chronic ulcerative pulpitis. 

2. Chronic hyperplastic pulpitis. 

3. Necrosis and gangrene. 

IV. Retrogressive metamorphosis of pulp tissue: 

Atrophy and degeneration. 



CHAPTER V. 

GENERAL PRINCIPLES OF DIAGNOSISOF DISEASESOF 
THE DENTAL PULP. 

Before entering into a detailed discussion of the clinical appli- 
cation of the diverse methods employed in the examination <»t'a 
diseased pulp, let us briefly reiterate what is generally understood 
by "diagnosis." It is the art of distinguishing one disease from 
another and its objed is to enable the practitioner to recognize: 
The existing disease by a specific name. 
(b) The respective stage and the peculiarities of the disease. 
c The existing or possible future danger. 

From the viewpoint of the dental clinician, it is of interest to 
ask what practical values are derived from a diagnosis? Some 
operators make the radical statement, with but slight modification, 
that a pulp which has been painful for a more or less prolonged 
period should be devitalized at once without further consideration, 
and they regard a correct diagnosis of the various diseases of the 
pulp a-- being of little practical value. The opponents of such 
radical views look more favorably on the conservative management 
of this delicate organ and to them the respective state of health of 
the pulp is of paramount importance in regard to it- further con- 
servative treatment. The ancient medical axiom. "Qui I 
diagnoscit, bene medebitur" which may be freely translated: "A 
good diagnostician is a good physician," should also be applicable 
to the conscientious dental practitioner. 

The correct interpretation of the various principles involved in 
the recognition of disturbances of the pulp arc of the utmost import- 
ance for the future preservation of the involved teeth. Each 
definite type of pulp disease requires specific treatment for its 
amelioration and unless the clinician recognize this fact he does 
imt render bis best services to hi- patient-. 

The purpose of the practice of clinical dentistry, considering it 
in it- broadest sense a- a branch of the healing art, i^ t<> institute 
preventive measures, to relieve suffering and to cure disease. 
These objects are nol achieved l>,\ the haphazard utilization of a 
few ped therapeutic Formulas or by certain mechanical 

procedures, but the} are based on a thorough knowledge of clinical 
pathology . 



DIAGNOSIS OF DISEASES OF THE DEXTAL PULP 63 

To support our contention regarding the diagnosis of diseases of 
the pulp, let us cite a few illustrative cases. AYithout having 
made a correct diagnosis, arsenic is placed upon a suppurating pulp. 
Practically no results are obtained, since this drug is a protoplasm 
poison which does not act on necrosed tissue. Nevertheless, the 
drug is made to carry the blame of its failure to act upon the remain- 
ing pulp stump. If the necrosed tissue is removed and arsenic is 
placed on the highly inflamed pulp remnant without having pre- 
viously relieved the inflammation, intolerable pain is absolutely 
certain to follow. Again the drug is blamed for its unexpected 
action. Or a patient may present himself with severe pain in an 
otherwise sound upper first molar. After a few routine applications 
of aconite and iodin have been made without obtaining the desired 
results, it is decided to devitalize the pulp with arsenic. Many 
visits of the patient are necessary, and the "painless killing" of the 
pulp turns out to be a barbarous joke, and all this expenditure of 
time, nerve force and money on account of inexcusable pathologic 
ignorance on the part of the practitioner is wasted. A diagnostic 
inquiry might have revealed the fact that tins patient suffered from 
a severe attack of influenza, which is prone to cause hematogenous 
infection of other tissues, and in this particular case, the pulp of the 
involved tooth, or teeth, may have been a point of lowered resistance. 

A correct diagnosis of a normal, a diseased or a dead pulp in 
.situ, is always a matter of great difficulty, and the difficulty is 
materially increased if the tooth under consideration does not 
present any visible signs of derangement or if the objective com- 
plaints as made by the patient are of an obscure nature. 

The intelligent interpretation and the harmonious correlation of 
the various data as obtained from a verbal examination of the 
patient and the diverse methods involved in a physical inspection 
of the diseased tooth tax the diagnostic skill of the operator to the 
utmost. It should be emphasized that only those who possess a 
sufficiently broad knowledge of the fundamental sciences of the 
medical art, an extensive experience and a keen analytic mind, will 
ever master the difficulties involved in diagnosing the diseases of 
the pulp in their entirety. The decision of the " lightning" diagnos- 
tician should be looked upon with skeptical reserve, and the diag- 
nostic report as rendered in absentia by a roentgen-ray laboratory 
technitian from a roentgenogram with the stereotyped arrow 
pointing to a spot about the apex of a tooth may be regarded as an 
aid to, but not as a diagnosis. 

Special Procedure in Making a Diagnosis.— In making a diagnosis 
it is always advisable to follow a systematic scheme in order to 
avoid mistakes of omission. Suitably printed examination charts 
in which the obtained data may be quickly entered are valuable 



64 



i SE& "l THE DBS TAL PULP 



1 ) \ 1 i 




1 )i ^GNOSIS ( 'it \i; i . 
L9... 


No 






rred b 




Name 




Add] • 






Ml. 


B.M.W. Nativity 


( Occupation 






Ant cedent history 
History of present t rouble 
( Seneral healt h 
Mucous membrane 
Bwellinga 

Maxillary >inus 

Mandibular joint 
< Condition of the teeth 
t Iharaoter of pain: Lancinating 
dull gnawing 

Duration Of painful attack 

Pain brought about by: Heat 

[rradiation: Mental region 

fronto-nasal region 

. hii ■ i .- 1 1 region 
mandibular region 
ination of teeth: Exploration 
transillumination 

percussion palpation 



Gums 

Fistulas 

Tongue 

Mandibular lymph nodes 

throbbing shooting 

spontaneous intermittent 

[ntermissdon 
cold pressure 

hyoid region 
ti mporo-maxillary region 
superior laryngeal re 
vertical region 

color 
Conduction <>f temperature 
impaction 



occlusion 

lit test 



malformation 



calculus 



g 7 6 5 1 3 2 l l _' :; 1 6 8 - - 



8 7 6 5 4 i 






• ; : 1 rine 



Blood 

• iologic 
Pathologic 



rk> 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 65 

aids in saving time and in preserving uniform records. 1 Aside from 
the dental diagram and general record columns as ordinarily out- 
lined on these charts, space should be provided for recording the 
findings of the special examination. 

The examination of a diseased pulp should include: 

1. The antecedent and present history of the case. 

2. Manifestations of pain. 

3. Physical examination of the tooth: 

(a) Exploration and inspection. 

(b) Color. 

(c) Transillumination. 

(d) Conductivity of temperature. 

(e) Percussion and palpation. 
(/) Roentgenogram. 

(g) Testing of the pulp by the faradic current. 

4. A differential diagnosis. 

The Antecedent and Present History of the Case.— The anamnesis is 
of the utmost importance; frequently the decision of a diagnosis 
hinges upon the facts obtained from an historical examination. 
Inquiry into possible hereditary taints, such as syphilis (Hutchin- 
son's teeth, necrosis), into the causes of the present disease as a 
sequence of some previous disease, such as rheumatic affections, 
colds, antral infection, malaria, influenza, etc. (idiopathic or 
secondary pulpitis); occupation, as working in acid or match 
factories (dissolution of the crowns of the teeth, phosphorus necro- 
sis); handling of lead, mercury, bismuth, etc. (stomatitis), glass and 
sand-blowing (abrasion); glucose and candy-making (candy- 
makers' caries) ; turning of mother-of-pearl (pericementitis) ; clay- 
pipe smoking (abrasion); chewing of straw and grain (actinomyco- 
sis) ; the use of certain tooth preparations, as charcoal tooth powder 
(tattooing of the gums) ; biting of the thread by seamstresses (peri- 
cementitis), etc., and specific events in the past or recent history 
of the patient, including its prodromes and suspected causes, are 
of diagnostic value. 

1 A convenient way of indicating the various teeth on a record card consists in 
utilizing a right angle in connection with the number of the respective tooth as 
employed in the following diagram: 

87654321 | 12345678 
R 



87654321 | 12345678 

The horizontal line of the angle indicates whether it is an upper or a lower tooth, 
while the position of the perpendicular line designates the right or left side of the 
jaw, i. e., i] — upper right first molar; \» — lower left canine, etc. Roman figures 
may be used to indicate temporary teeth and the mathematical sign V rnay be 
employed to designate roots. Or the first capital letter of each tooth may be used 
by placing the number of its position in the arches at its respective corner. Thus 
the upper right first molar is designated as M 1 ; the lower left second premolar as 
P2, etc. For the designation of the temporary teeth, Roman figures may be employed, 
i. e., the upper right second incisor, J 11 . 
5 



DJSEA $E& 01 THE 1>E\ TAL I'l LP 

Manifestation of Pain as subjectively expressed by the patient 
provides the diagnostician with the most reliable information con- 
cerning the nature of the existing ailment. The importance of 
it- interpretation must be obvious as almost 90 per cent of all 
diseases either begin with, or have, pain as a prominent symptom 
at some time during their course. Pain Is an expression of disease; 
it is the conscious manifestation of a morbid change causing distress, 
of when extreme, agony, within the sensory oerve centers brought 
about 1»\ some form of irritation, and it is always referred t<> the 
periphery . 1 1 is a sensation feared by man, the alleviation of which 
is constantly attempted by the physician, although it is his most 
reliable assistant. It is the monitor of approaching ill, and, inci- 
dentally, it is the criterion of the intensity of a traumatic insult. 
To its relentless demands the most obstinate patient has to submit 
Unconsciously, the patient seeks to protect a painful organ. 

"Tain is a severe but necessary law of Nature, but, like all her 
laws, it is undeviating in its course; it appears not only as a bene- 
fieient monitor, but also as a useless tormentor. Pain is necessary 
Cor guarding us in the fight against the forces of disease; it precedes 
or accompanies the outbreak of most diseases, and warn- us that 

the l)od\ is sick and needs attention, although often it may be 

absent in the most dangerous diseases, thus giving the patient 
false assurance. The outward expression of pain is by no means 
a guide to its actual intensity, as pain Largely depends upon the 

psychic condition of the patient." (Cioldseheider. ) 

An analysis of pain should be begun by differentiating it- prop- 
erties, i. <.. quality, intensity and duration and by having the 
patient point out exactly the spot or the region in which it is felt. 
If the pain is of a radiating character it is accessary to differentiate 
between the painful focus and its peripheral radiations. Frequently 
it will be observed that the painful focus coincides with the area 
in which the pain was localized at the beginning of the attack. 
However, occasionally ;> pain may radiate' in various direction-- and 
ma\ run a most irregular course. Incidentally, with the location 
of pain, the time <>f it- appearance deserves some consideration. 

The onset of pain may be associated with some definite hour of 

the day, or it maj be coincident with and dependent on certain 
occurrences, such as the ingestion of food, the application of heat 
or cold, etc. The duration of the painful sensation must also 
recen e due at tent ion. 

"The intensity of pain, judged from its quantitative variations, 
depends partially on the intensity of the irritation causing it and 
partially on the psychic characteristics of the patient. 'The same 
etiologic stimulus, which ma} be endurable to one person, ma\ 
seriously disturb the psychic equilibrium of another. 'This double 
dependence of the intensity of the painful sensation on stimulus 
and irritability, and the impossibility of projecting externally the 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 67 

psycho-chemic events in the sensory nerve substance that take 
place when pain is experienced, render illusory an attempt to esti- 
mate the quantity of the sensation for diagnostic purposes. ' ' (Schmidt.) 

The quality of the pain as expressed by the patient is a relative 
term, although frequently much information may be gained from the 
description which he gives. Such descriptive terms as pain of a 
boring, throbbing, fulgurating, lancinating, radiating or diffuse 
character, or many other similies, such as gnawing, jumping, etc., 
are merely clinical expressions of the quality of the painful sensa- 
tion. An exact analysis of the existing pain demands an accurate 
determination of all the factors which influence the intensity of the 
sensation, either in the positive or the negative. Such modifying 
factors are intimately connected with the causative condition, and 
are, therefore, of the greatest importance from the viewpoint of 
the diagnostician. Various modify ing agencies greatly influence 
differences in the individual painful susceptibility of certain parts 
or of the body as a whole. Psychic disturbances, i. e., excitement, 
suggestion, diversion of attention, race, sex, age, education, self- 
control, etc.; mechanical, /'. e., position of the body, motion, per- 
cussion, pressure, etc.; thermal, i. c, changes of the weather, cold, 
draft, etc., and chemical, either dietetic or remedial, are important 
controlling factors of psychic evolution. There may also be asso- 
ciated manifestations of a subjective or objective nature. While 
some of these manifestations may be remote in their nature, as, 
for instance, vomiting in severe neuralgia, others may be interpreted 
as being actual symptoms. 

In regard to the kind of pain as subjectively expressed by the 
patient, it is well to interrogate him by a set of routine questions, 
as, for example: At what side of the jaw is the pain felt?. Which 
is the painful tooth? When did it begin to ache the last time? 
How long did the pain last? Does cold or hot water hurt? Does 
the tooth ache on closing the jaws? Does it feel longer than the 
other teeth? Does the pain increase on lying down or in coming 
from the outside cold into a warm room? If a tooth is filled, addi- 
tional inquiries are necessary, /'. e., Had the tooth ached before the 
rilling was placed? Did it pain during filling or soon thereafter? 
Was the "nerve" destroyed? If a carious defect is present in the 
tooth under consideration, the application of certain chemicals to 
the carious spot also may furnish fairly valuable diagnostic hints. 
The application of a few drops of a 5 per cent formaldehyd solution 
or of diluted alcohol (50 per cent) into a deep-seated cavity will 
call forth a series of painful reactions. Depending on specific 
conditions, as, the presence of acute febrile diseases, especially 
malaria, influenza and rheumatic affections, of neuralgic tendencies, 
anemia, menstruation, pregnancy, etc., other questions, of course, 
will suggest themselves. 

An important contribution to the comprehension of the compli- 






DISE iSES OF THE DENTAL PI LP 



cated subject of reflex odontalgia, from a clinical point of view was 
made by the English neurologist, Henn Head, some twenty-five 
\ ears ago. 1 By ;i carefully conducted series of observations extend- 
ing over man} years, this experienced clinician was able to show 
that there existed a definite relationship between certain visceral 
diseases of the head, throat and abdomen with well-marked zones or 
areas of superficial tenderness on the skin in the neighborhood of 
the affected organs. Head postulates, that segments of the spinal 
cord, which receive painful impressions from internal organs along 
their sensory track, become painfully altered. Any other sensory 
impulse, which is conducted from the surface of the skin to the same 
segment must, necessarily, increase the existing alteration. The 




I Head's reference areas as related to the teeth. (Feilcr.) 



resultant increased sensorial impression is conveyed to the cere- 
brum and is recognized as a proportionally increased painful sen- 
sation. Diseased teeth bear a definite relationship with one or 
more surface areas. Head assumes that "To these area-, pain is 
referred, and over them the skin may become tender when the 
normal condition of that organ is disturbed." Head's teaching 
the location of painful areas about the face as related to the teeth 
is not yet universally accepted; nevertheless, it constitutes one of 
the most important contributions to neurology and it i- of inestim- 
able valu< in the diagnosis of obscure reflex odontalgias. 



II ition wiih special referent 

MI . 1894 



! he pain <>f \ 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 69 

Head has divided the general topography of the head and neck 
in regard to referred painful conditions as associated with the teeth 
into reference areas. According to his conception, each tooth 
seems to have a separate area of pain reference, i. e. : 

Upper Jaw. 

Tooth Reference area 

1. Incisors Frontal region. 

2. Canine Naso-labial region. 

3. First premolar Naso-labial region. 

4. Second premolar Temporal or maxillary region. 

5. First molar Maxillary region. 

G. Second molar Mandibular region. 

7. Third molar Mandibular region. 

Lower Jaw. 

8. Incisors Mental region. 

9. Canine Mental region. 

10. First premolar Mental region. 

11. Second premolar Hyoid or mental region. 

{Hyoid region; also in ear and just 
behind angle of the jaw. The 
tip of tongue on the same side is 
also tender. 
14. Third molar Superior laryngeal area. 

The general topography of the principal clinical painful areas is 
as follows: 

I. Fronto-nasal Area.— The maxillary incisors refer their sensation 
to this area, being situated about f inch outward from the median 
line of the face and extending about 2\ inches above the root of 
the nose. Its maximal point may be found upon the orbital ridge 
of the frontal bone about § inch from the median line. 

II. Naso-labial Area.— The maxillary canine and first premolar 
refer their sensation to this area, covering a part of the upper lip, 
the lower lip and the under surface of the nose and a part of the 
cheek. Its maximal point may be located upon a horizontal line 
extending about \ inch from the corner of the mouth. 

III. Temporal and Maxillary Areas.— The upper second premolar 
refers its sensation to the temporal and sometimes to the maxillary 
area, however in no case is there a simultaneously existing hyper- 
algesia in both areas. The first molar is claimed to refer its sensa- 
tion to the maxillary area only. The maximal point of the temporal 
area is to be found in the temporal fossa, immediately above the 
upper border of the zygoma. The maximal point of the maxillary 
area may be located a little below and to the left of the infra- 
orbital foramen. 

IV. Mandibular Area.— The upper second, and in most instances, 
the third molar, refer their sensation to this area, although the 
third molar occasionally reflects its sensation to the hyoid area. 



m 



DISE iSES OF THE DEh I'M- PULP 



The maximum point of the mandibular area is to be Found on n 
vertical line From | to I incb in fronl of the tragus of the car. 





> 



l-'n.. _'_'. The fronto-nasal area (M axil- Fig. 23. The nasolabial area. Maxfl- 
lary incisors.) In this and the succeeding lary canine and firsl premolar.) 

figures the "maximum spots" of intensity 
of pain are indicated bj a round white dot. 





I Maxillary rhe maxillarj 

>nd premol Maxfllars Beeond premolar or firsl 

mol 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 



71 



V. Mental Area.— The two mandibular incisors, the canine and 
the first premolar refer their sensation to this area which covers 
a rough triangle, including the mental foramen. Its maximal 





Fig. 26. — The mandibular area. (Maxillary 
second and third molars.) 



Fig. 27. — The mental area. 
( Mandibular incisors, canine and 
first premolar.) 





1 1 



Fig. 28.— The hyoid area. (Mandi- 
bular second premolar, and first and 
second molars.) 



Fig. 29. — The superior laryngeal area. 
(Mandibular third molar.) 



72 DISEASES OF THE DENTAL PULP 

point is situated on a vertical line dropped from the angle of the 
mouth and slightly in trout of the mental foramen. 

VI. Hyoid Area. The second premolar usually refers its sen- 
sation to the hyoid area, although occasionally it may be referred to 
the mental area. It covers a pari of the ramus and it partially 
reaches behind its posterior border, extending up to the mastoid 
process of the temporal bone. Maximal painful points may be 
located in the externa] auditory meatus, frequently giving rise to 
earache and at other times directly below the angle of the mandible. 

The first and second lower molars also refer their sensation to 

the hyoid area. 

\ II. Superior Laryngeal Area. —The third lower molar refers its 
sensation to this area which practically covers the sternocleido- 
mastoid muscle and its maximal point may be located directly in 
front of the anterior border of the above muscle, I. 0., near the 
laryngeal protuberance. Occasionally reflex pain arising from a 
lower third molar may he referred to a rather distant /one. i i .. 
the vertical area located at the to]) of the skull either at the right 
or the left from the median line and on a connecting line drawn 
from the upper tips of the ears. 

Absence of pain, or analgesia, in otherwise normally sensitive 
structures, should also he noted. u Analgesia may be cither central 
or peripheral. When central, the lesion may be in the brain or 
spinal cord. When it is in the brain it may he either endogenous 
or exogenous. Endogenous analgesia is present during severe 
emotion, such as great joy, anger and fear, as is seen in the disap- 
pearance of a toothache as soon as the patient enters the dentist's 
office, or the cessation of pain when the patient is in mortal terror. 

It may he present during arduous mental work which requires great 

concentration of thought, and also in states of mental exaltation, 
such as exhibited by religious zealots, examples of which are the 
Buddhist fakirs." (Behan.) Complete analgesia of the dental 
pulp may be a most early important symptom of locomotor ataxia. 
Exploration and Inspection. A careful examination of the teeth 
by exploration and inspection cannot be overestimated as failure 

to discover even a small defect or lesion might result in subsequent 
serious consequences. Exploring instruments of various angles and 
curves arc available for such purposes. Mouth mirrors, cither plain 

or with a concave surface, a small magnifying glass, silk floss to 

detect lesions or roughness on the approximal surfaces of the teeth, 
an air syringe and absorbent paper to remove moisture, napkins, 

Or the rubber dam to keep the parts dry, etc.. are all Decessary 

adjuncts in conducting a careful examination. Preferably, the 

examination is started at the median line of the left upper arch. 

examining each tooth in succession back to the last molar and then 

gain at the median line of the right side in the same 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 



73 




manner. The lower arch should then be examined similarly. All 
the defects of each individual tooth should he marked at once on a 
suitable chart. 

Color.— The color of a tooth varies 
within very narrow limits. A differenti- 
ation should be made between superficial 
stains as caused by tobacco, chemicals, 
food, drugs, etc., and bodily discoloration, 
as a sequence from death of the pulp. 
Superficial discoloration may be brought 
about directly by the various filling 
materials or indirectly by the forma- 
tion of metallic salts and oxids from 
amalgams, metallic posts, etc., by recur- 
rent caries under the fillings or by leak- 
age of the filling. Death of the pulp 
usually produces various shades of dark- 
ening of the tooth, ranging from a brown- 
ish-yellow discoloration to a slaty-gray or 
almost black color. 

Transillumination.— Transillumination of a tooth by 
means of an electric mouth lamp may furnish a fairly 
well-outlined shadow picture of its living pulp; the 
picture is diffused when a dead pulp is present. Owing 
to the variety in thickness of the crowns, the anterior 
teeth are more easily transilluminated. In the pre- 
molars and especially in the molars the thick body of 
the tooth crowns materially obstructs the passing 
rays. The transparency of a tooth may not be altered 
perceptibly by the death of its pulp. Transillumination 
should always be conducted in a dark room, so as to 
intensify the shadow picture of the pulp. 

Conductivity of Temperature. — A pellet of heated 
gutta-percha, or some other heated material which is a 
poor conductor, is placed on the surface of the suspected 
tooth. A tooth with a diseased or dead pulp does not 
respond in the same manner as a tooth with a normal 
pulp. A suppurating pulp usually responds quickly 
to a temperature above the normal; an acute inflam- 
mation of the pulp is often recognized by the applica- 
tion of cold water or the ether or ethyl chlorid spray, 
while a dead pulp does not respond at all. By contin- 
uity the heat rays may produce a response from the 
pericementum. The thickness of the tooth structure 
and the presence of various filling materials may, ac- Fig. ac- 
cording to their phvsical nature, increase or decrease Ma snifymg 

., i •• •. !• j i examination 

the conauctivitv ot temperature changes. g l ass 



74 



DISEASES OF THE hi:\ 7.1/. ri i.r 



I 



VValkhoff makes the statement thai the normal pulp will not 
reac< between 50 I'. (10 C.) and l-'" I'. IS C. . Pain produced 



r\ 



fo 



1 

I ■'!'.■ 31. Exploring instruments. 




b; water below 90° F. (32° C.) indicates, according to his concep- 
tion, inflammation, while pain produced by water heated above 
tin- temperature indicates a suppurative condition. A mosl 




I i«.. 32. ( Cameron's opalite lamp. 

jnteresting exhibition of the thermal reactions of the pulp has 
! ,e f n .Jf ven u > the late Louis Jack. He has shown that some 
•ndividuals readily tolerate temperature changes as applied to their 



CAMERON'S D1AGNOSTOLITE 

PAT '- DfcC - »*' ' »J 6 .^M.^M^ 




' ameron'a diagnostolite 



\:: U '"';':' I"- '''•J','- "'•■ '•'-' C. below and between 
l|s ' ,v ' ■ "' '■- ' 57 C. above the normal te srature 



DIAGNOSIS OF DISEASES OF THE DEXTAL PULP 75 

of the body. Some patients will experience pain between 75° to 
77° F. (24° to 25° (\), while others will not complain even above 
145° F. (6)3° C). 

Percussion and Palpation.— Percussion is best performed by strik- 
ing the tooth a sharp blow with the butt end of a steel instrument. 
The peculiar dulness of the resultant sound of a tooth with a suppu- 
rating or dead pulp as compared with that of a normal tooth can 
be usually distinctly discerned by the trained ear. The dulness of 
the sound is brought about by inflammatory changes of the peri- 
dental membrane as a sequence of a diseased or dead pulp or from 
external causes. The infiltration of fluid between and in the fibers 
of this membrane changes the relationship of the tooth to the 
alveolar bone, and consequently the sound waves produced by the 
tapping have not that full, clear tone which we perceive from a 
similar percussion of a tooth with a normal pulp, or one that is 
merely diseased without Inning affected the peridental membrane. 
If the finger ball is placed over the apical region of a tooth afflicted 
with a marked absorption area of its alveolus and its crown is 
tapped with a steel instrument, a characteristic thrill, known as 
fremitus, is imparted to the finger-tip, which is absent in a tooth 
encased in a healthy bony structure. 

Roentgenograms. — Roentgenograms are always serviceable, and 
should be insisted upon in every case of doubtful diagnosis. The 
correct interpretation of a roentgen-ray picture comprises a thorough 
familiarity with the normal anatomy and its variations and with 
the clinical pathology of the involved structure combined with a 
comprehensive knowledge of the appearance of these same structures 
under the roentgen rays. It must he clearly understood that a 
roentgenogram merely depicts a verified gradation of shadow casts 
produced by the passage of the rays through substances of different 
density. Dark areas on the negative indicate places lessened in 
their density, i. e., the rays pass through these rarefied tissues more 
readily than through the surrounding structures. The roentgeno- 
gram does not indicate the physical nature of these rarefied areas. 

Ordinary roentgen films or plates do not offer any perspective 
view of the object, as only two dimensions are portrayed in the 
picture. For routine diagnostic purposes such views answer quite 
well. A more accurate knowledge is gained from stereoscopic 
pictures or from two or more roentgenograms taken at different 
angles. 

To facilitate the intensifying of the very important minute 
details which naturally will assist in the correct interpretation of 
the roentgenogram, numerous devices have been suggested. The 
principle involved in the use of these apparatuses centers about the 
advantages obtained from the intensified contrasts between light and 
darkness and in the magnification of the object. The Columbia 



76 



DISEASES OF Till-: DENTAL PI LP 



Magnifying Uadioscope and the Blum Binocular Dentascope are 
useful instruments for such purposes. 

Acute types <>t' periapical disturbances of verj recent date are 
usually not discernable in the roentgen-ray picture, since rarefac- 
tion of the Involved areas as yel lias not occurred. Chronic < li>- 




1 i... :; I. Normal bone tissue aboul 
i he upper molars. 




Fin. .'!."). Normal bone tissue aboul 
i he lower molars. 





i... 36. True gemination <>f upper 
firsl incisors. 



Fio. ■ <. . Fused upper firsl incisor* 




I i'. 38 Palatal rool of upper 
molar overlapped by distal rool 
wrongly diagnosed as granuloma. 




In.. .">'.». ( 'hronir :il«- 



turbances of tin- tissues surrounding the rool of a tooth are more 
or less pronouncedly manifested since the existing osteitis offers 
less resistance t<» the passing rays. The disturbances include 
chronic proliferating pericementitis, either singly or associated \\ itli 
osteitis, with m granuloma or with b cyst. The suppurative type 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 



77 



with a rarefied area about the apex of a tooth which is filled with 
pus, or pus discharging through a fistula, is clearly depicted. Pyor- 
rhea alveolaris alwavs shows marked areas about the affected teeth 




Fig. 40. — Chronic abscesses and 
granulomas. 




Fig. 41. — Radicular cysts. 





FiG; 42. — Radicular cysts. 



Fig. 13. — Pyorrhea alveolaris. 





Fig. 44. — Pyorrhea alveolaris. 



Fig. 45. — Split root. 



and the involved bony structure; this is equally true of a granu- 
loma, a cyst and premature or senile alveolar atrophy. 

Electric Examination.— A weak faradic current, as induced by 
the induction coil in its passage through the body of a vital tooth, 



7s DISEASES OF THE DENTAL I'l I.I' 

produces a more or less pronounced reaction which is an expression 
of the sensorial innervation of it- pulp. Bj carefully gaging the 
current, the resulting irritation expressed as sensation becomes the 
mosl valuable diagnostic agent in determining the stage of the 
vitality of the pulp. The information obtained with the electric 
pulp tester is ^<> verj gratifying that the method of its application 
needs to be discussed in detail. 




Fig. in. Columbia magnifying radioscope. 




! to. 17. Mliiin binocular denfc 



Electric Pulp Tester and Its Accessories. History. In a remark- 
able book, Treati8i on Denial Caries, by Magitot Paris, 1867) and 
translated bj Chandler Boston, L 878), the following statement is 
recorded: "This examination of the dental system . under 
circumstances so >bscure, demands careful attention 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 79 

Another method has also been proposed; it consists of causing an 
electric current to pass along the whole extent of the dental arches 
by means of one of the little induction apparatus so frequently 
employed nowadays in medicine. By the passage of a current so 
feeble as not to cause of itself any pain, the carious tooth will 
become the seat of an acute and clearly localized pain." 

John S. Marshall, in a paper entitled "Electricity as a Thera- 
peutic Agent in the Treatment of Hyperemia and Congestion of 
the Pulp and the Peridental Membrane, 1 ' makes the following 
statement: "As a means of diagnosis in obscure cases of the vital- 
ity or non-vitality of the dental pulp, I know of nothing so sure to 
demonstrate to a positive certainty these conditions as the electrical 
currents, both the galvanic and the faradic. In the more obscure 
cases, however, the faradic is superior to the galvanic, for if there 
is the slightest vitality remaining in the pulp it will demonstrate 
it instantly by causing a response in the tooth." 

In 189G Woodward 1 demonstrated the following: "If a few cells 
of a cataphoric apparatus are in action, and the positive electrode 
be applied to the dentin or metallic filling in a vital tooth, while 
the negative pole is at the cheek or wrist of the patient, a distinct 
sensation should be felt, while in case of a dead pulp there will be no 
response; usually even a small rilling will transmit a distinct shock 
in a vital tooth, which is absent in a devitalized tooth. A mild 
interrupted current has also been used for the test." 

The recommendation of testing the pulp by the electric current 
has never received the indorsement of the dental profession which 
it justly deserves. In 1902 Puyt 2 published his researches: "Con- 
cerning the use of weak interrupted currents for the purpose of 
locating certain diseases in the pulp." About the same time, but 
independent of Fuyt, Hafner 3 utilized the reduced direct current 
for this same purpose. A year before the publication of Fuyt's 
and Earner's observations, Schroder had used the secondary electric 
current for diagnosing diseases of the tooth pulp and he published 
his observations in the annual report of his institution. Since then 
quite an extensive literature on this interesting subject has appeared, 
the most important publications being those of Witthaus, 4 Grevers, 5 
Hamburger, 6 Frohmann, 7 Plesse, 8 Ander Lahn, 9 Schroder, 10 Tousey, 11 
etc. 

1 Woodward: Proc. Philadelphia Academy of Stomatology, 1896. 

2 Fuyt: Zahniirztliche Rundschau, 1902, p. 533. 

3 Hafner: Schweiz. Vierteljahresschrift fur Zahnheilkunde, 1902, No. 4. 

4 Witthaus: Deutsche Monatsschrift fur Zahnheilkunde, 1907, No. 11. 
6 Grevers: Dental Cosmos, 1903, p. 58. 

6 Hamberger: Deutsche Monatsschrift fur Zahnheilkunde, 1907, No. 6. 

7 Frohmann: Ibid., 1907, No. 3. 

8 Hesse: Ibid. 

9 Ander Lakn: Oesterr.-ungar. Vierteljahresschrift fur Zahnheilkunde, 1907, No. 2. 

10 Schroder: Der Inductionstrom als Diagnosticum in der Zalmarztlichen Praxis, 
1907. 

11 Tousey: Dental Cosmos, 1909, p. 513. 



80 



DISEASES OF THE DENTAL I'l LP 



It i- interesting t<> note that the various observers differ a- far 
as the nature of the electric current is concerned. Fuyt advises 
the primary current and Schroder uses the secondary current of the 
faradic battery, while Eiafner advocates the reduced direct current. 
The alternating current cannot be used tor such a purpose unl< 
generator he interposed to change it to a direct current. All 
investigators, however, obtained precisely the same results. To 
judge from the various publications on the subject, coupled with 
our observations, the primary and secondary combined faradic cur- 
rent i- best suited tor this work on account of the simplicity of the 
apparatus and the easy manner in which this current can be regu- 
lated. 




Ii',. 49. —Induction coil pulp tester. 



The Faradic Current and Its Accessories. The faradic battery 
delivers an easily controlled current of minute quantity. Two 
forms of induction coils, in connection with the battery, arc in 
general use the induction coil with a core shield the tube of 
Duchenne) and the sledge induction coil of Du Bois-Raymond. The 
source of electricity for the smaller induction coil is usually received 
from a single dip battery (acid potassium bichromate solution or 
an >rdinary dry cell, while the sledge induction coil may be fed 
from a series of batteries, or from the streel current reduced by a 
rheostat. The small induction coil with one dry cell battery gives 
universal satisfaction and on account o'i it- cheapness, simplicity 
and easy transportation deserves to he recommended. More com- 
plicated types of apparatuses may be obtained from electric or 
dental supply houses. The induction coil produce- a secondary 

current in a circuit placed near to. hut not in contact with, the 

galvanic field. This galvanic field, the primary current, i- repre- 
sented l>\ three or four layers of coarse wire wound about a hollow 
Don-conducting cylinder, and the two ends of which are united 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 81 

with the binding posts. Within the cylinder is found a core of soft 
iron rods, which are covered in the simple induction coil bv a 
movable brass tube (the tube of Duchenne). Outside of the core 
and the primary current is a second coil, usually consisting of a 



or* 




50.— Columbia pulp tester and ionization apparatus. 



(Wall model.) 



great many turns of fine popper wire. The ends of this coil are also 
connected with the bmding posts. When the current from the cell 
passes through the coil of coarse wire -the primary current-a 
current ,s also mduced in the secondary coil of hue wire because 
the passage of the primary current makes the iron core strongly 



82 DISEASES OF THE DENTAL PULP 

magnetic. A vibrator is placed in close proximity to the iron core. 
When the current passes through the primary coil and becomes 
magnetized, the steel spring of the vibrator is attracted and breaks 
the <iirmit. The magnet is now immediately released and the 
spring reasserts itself. The control of the current is guided by 
moving the brass tube; the gradual removal of the tube incn 
the current and vice versa. To furnish an approximate guide of 
the strength of the current, the tube of Duchenne is divided into 
ten equal parts by making file mark-, or by pasting a narrow strip 
of paper, on which the divisions have been registered, on the tube. 
The divisions are referred to as degrees. In the sledge induction 
coil of Du Bois-Raymond the secondary coil is moved bodily over 
the primary current. The registration of intensity is marked on a 
scale fastened to the apparatus, which is divided according to the 
size of the apparatus in 10, 50 or 100 degrees. This instrument is 
much more sensitive than the tube induction coil, and an exact 
differentiation between the various degrees is more readily obtained. 




lid. 51.— Insulated electrode holder. 

The small l'aradic batten carries three binding posts and furnishes 
three definite currents. Posts 1 and 2 furnish the mild primary 
current, po>ts 2 and 3 furnish the more intense secondary current, 
while posts 1 and :'> furnish the strong combined currents. The 
metallic electrode fastened to one pole is held in the hand by the 
patient, while the other pole carries the conducting cord, to which 
a specific dental electrode is attached. Whether the respective 
electrode is attached to the positive or the negative pole is of no 
consequence a- the direction of the passing current doc- no1 influ- 
ence the results. The dental electrode may consist of a piece of 
hard rubber in the form of a penholder, with a piece of German 

silver wire passing through its body. A socket is left at each end 

for the attachment of the conducting cord and the copper point. 
The latter i- slightly roughened to earn a -mall piece of wet cotton; 

it may be bent to any desired angle and sterilized in an open flame. 

A hard rubber electric needle holder with contact -witch inter- 
rupter' a- used by the dermatologist for the removal of hair and 
which may be procured from surgical supply houses makes a most 

Meabic dental electrode. 
The Action of the Faradic Current on the Pulp. The diagnosis of 
the condition of the pulp for clinical purposes resolves it-elf into 
the recognition of h\ peremia, acute simple and suppurating inflam- 
mation and death of the organ. The action of the electric current 

on a sound tooth call- forth a definite sensation w Inch i- the phj sio- 



DIAGNOSIS OF DISEASES OF THE DENTAL PULP 83 

logic expression of the normal reaction of a patient to electric 
stimulation. The strength of the current needed for this purpose 
varies with the individual. The reaction manifests itself in a 
peculiar tingling sensation, but not in pain. This point is known 
as the "irritation point," or the threshhold of sensation. After 
having established the irritation point in a sound tooth of the 
patient, and after having expressed it in figures from the markings 
on the tube of Duchenne, it is a simple matter to distinguish a 
diseased or a dead pulp from a healthy pulp. By comparing these 
figures a reliable clue for the diagnosis of an existing disease of the 
pulp is furnished. The following scheme may serve as a guide for 
making a diagnosis: 

1. The normal pulp responds to the faradic current at its specific 
irritation point. 

2. The hyperemic pulp responds to the faradic current slightly 
below the irritation point. 

3. The inflamed pulp (acute simple pulpitis) responds to the 
faradic current always below the normal irritation point. The 
more intense the inflammation, the more ready the response to the 
current. 

4. The suppurating pulp (acute or chronic suppurative pulpitis) 
responds to the faradic current above the normal irritation point. 
The more intense the suppuration, the less ready the response to 
the current. 

5. The dead pulp (necrosis or gangrene) does not respond to the 
current, not even to its full strength. 

To illustrate this diagnostic scheme by figures as obtained from 
measuring with the tube of Duchenne, the following data may serve 
as examples: 

Degrees Diagnosis. 

1. Upper first incisor . . . 3.5 Normal irritation point. 

2. Upper right first premolar . 3.0 Hyperemia (tooth shows a slight 

carious defect). 

3. Lower right first molar . . 1.5 Acute pulpitis (tooth shows a deep 

carious defect). 

4. Lower left second molar . 7.5 Suppurative pulpitis (the tooth has a 

large compound amalgam filling). 

5. Upper left second premolar. No re- Dead pulp (the tooth has a large 

sponse from cement filling) . 
current. 

Technic of Applying the Faradic Current to the Tooth. —The metallic 
hand electrode is held by the patient, or a wet cork or felt electrode 
is fastened to his wrist. The other pole carries the dental electrode, 
which is manipulated by the operator. The current is started at 
its lowest voltage— i. e., the tube of Duchenne is completely pushed 
over the core, or the sledge is started at zero. The irritation point 
of the patient is now obtained by holding the dental electrode 
charged with a piece of moist cotton against any of the apparently 
sound teeth. A tooth corresponding to the one under observation 



84 DISE iSES OF THE DENTAL PULP 

is preferably selected for this purpose. The wet cotton of the 
electrode Is placed near the (-(Miter of an accessible surface of the 
selected sound tooth, l>ut always away from a present filling. The 
tube is now gradually withdrawn until slight, bul distinct, sensation 
is felt l>\ the patient. The sensation must never he expressed as 
pain. The number on the scale of the tube is read and the same 
maneuver is repeated on the suspected tooth. The deduction 
obtained by comparing the two readings furnishes the Irritation 
point of the diseased tooth. The average irritation point is not the 
same for every tooth and for everj patient. A layer of thick enamel 
on a heavy body of dentin requires a stronger current and vice versa. 
Consequently, the irritation point in the young i> usually lower 
than in old individuals. The respective condition of the nervous 
system of a patient also influences the response to the current; a 
disturbed psyche is usually more sensitive to electric stimulation 
than a normal condition. If the electrode is placed on or very 
close to a metallic filling in a vital tooth, the response i- very pro- 
nounced, and even painful, as compared with the same amount of 
current passing through a tooth without a metallic filling. This i- 
also true if the electrode is placed on a thin shell of enamel which 
covers a metallic filling. The severity of the shock depends on 
the nature of the filling. All filling materials with the exception of 
gutta-percha are better electric conductors than enamel. 

The tooth under observation must he dry, and not in too close 
contact with its neighbors, as the current may switch to an adjoin- 
ing tooth. The close proximity of large contour fillings or metallic 
crowns deserve special care. In such cases the rubber dam or 
strips <>f the dam placed between the adjacent teeth i- necessary 
for insulation. The electrode must not he placed too near the 
gum line, or the mini tissue may react before the pulp is reached. 
The sensation Pelt on the gum is quite different from that in the 
pulp. It is not acute, but manifests itself as a tickling or crawling 
sensation. Devitalized teeth which carry metallic fillings will also 
read if the electrode is placed on or near the fillings; they will not 
react if the electrode is placed on sound enamel provided that tin- 
root filling consists of gutta percha. If the root carries a metallic 
post a prompt -hock is felt from the current. If a present filling 
reaches the gum line a verj quick and painful response is experi- 
enced, even from a mild current, when placed in contact with the 
filling. The absence of enamel acts somewhat similar to the 
presence of a filling. A -hock i> usually produ< ed when t he current 
i> placed on exposed dentin which must, therefore, be avoided. 

\ tooth with a dead pulp, hut with a sound crown, ina\ also react 

to the current if an acute pericementitis is present. I sually, how- 
ever, a somewhat stronger currenl is required than thai which i- 

ai\ to establish the normal irritation point. In mult i-rooted 



DIAGNOSIS OF DISEASES OF THE DEXTAL PULP 85 

teeth the pulp may be dead in one canal and highly inflamed in 
another canal. In such cases a reaction similar to that obtained 
from suppurative pulpitis is usually observed. 

Disturbances involving the general nervous system, especially 
locomotor ataxia, manifest themselves in the teeth by a more or 
less complete analgesia of their pulps. In such cases, although the 
pulp seems to be apparently normal, the current produces no 
response. 

The examination of the pulp by means of the faradic current 
requires a thorough mastering of the many details connected there- 
with . The practitioner can best familiarize himself with the current 
by testing the instrument on himself or on an experimental patient. 
The teeth, gums, lips and tongue are organs which should pre- 
liminarily be tried. Before testing a tooth it is always advisable 
to establish, if possible, the irritation point in a corresponding sound 
tooth. The difference of the recorded figures furnishes the base for 
its diagnostic utilization. It is understood, of course, that no 
therapeutic measures (drugs) have been previously applied to the 
tooth under consideration or to the general system. Their presence 
would materially influence the reaction of the current. Morphin, 
for instance, if administered in average doses, will reduce the reac- 
tion of the current from three to four degrees below the normal 
irritation point, while chloral hydrate in 15-grain (1 gm.) doses 
acts within three to four minutes, and reduces the scale two to 
three degrees. 

All of the enumerated methods of diagnosing the respective state 
of health of the dental pulp should be looked upon as helpful aids, 
but by no means as absolute proofs. The results obtained with 
the faradic current are so very superior to all the diagnostic pro- 
cedures that its use for such purposes deserves to be highly recom- 
mended. Men with only limited experience in employing this 
apparatus have passed premature judgment regarding its merits 
and its shortcomings. Incompetence, as displayed in the utilization 
of a certain apparatus, does not necessarily indicate that the instru- 
ment is at fault. 

The direct diagnosis of an inflamed pulp by the various methods 
as outlined above should always be supplemented by a differential 
diagnosis in regard to a concomitantly existing disturbance of the 
peridental membrane of the affected tooth or of a general disease. 
This examination constitutes the absolutely necessary adjunct for 
a final diagnosis. The differential diagnosis of the pulp and an 
existing general disease is discussed under Secondary Pulpitis. The 
appended scheme may serve as a basis for a differential diagnosis 
of the inflammatory diseases of the pulp and the peridental mem- 
brane : 



86 



DISEASES OF THE DENTAL n LP 



Differential Diagnosis oi [nflammatori Diseasi 



The Dental Pulp. 

The pain Ifl "I" :i sharp. 1 : i u < • i 1 1 : 1 1 in- chat - 

aoter; in t he earlier Btagee i1 is dis- 
tinctly paroxysmal. <m assuming a 
recumbent position, <>r with excite- 
menl <>r fatigue, the pain usually 

iin t« 

The tooth is exceedingly sensitive to 
thermal changes; in its inceptive state 
cold: hit it on heal intensifies the pain. 

There i- no swelling of the sofl tissues 
aboul the tooth, and no tenderness to 
pressure. 

The tooth is not elongated nor does it 

strike first iii occlusion. 

At times it is quite difficult to determine 
exactly which tooth is affected as the 
pain induces reflex symptoms in other 

teet h and tissues. 

Percussion is negative. 

1 1 is possible to bite upon t he toot h and 
to use it in mastication without any 
special sensation if thermal extremes 
be a\ oided. 

The tooth Usually shows a carious de- 
fect. 

Swelling of t he mandibular lymph nodes 
is not observed. 



The Peridental Membrane. 
The pain is localized, dull, steady, boring 
or throbbing in character; it is not 
paroxysmal, nor increased by a recum- 
bent position. Pain remain- more or 
less constant without much reference 

to externa] conditii 

There is little reaction to temperature 
ohanges; cold may give relief, while 
heat does not materially affect it. 

Pressure at first usually relieves the pain, 
later it i- intensified. In the later 
Btagee swelling is common. 

The tooth is raised in it- socket and 
strikes before any of the others 

occlude. 

The diseased tooth is readily l< 
the pain is steady in degree and in its 
position. No i- flex symptoms are 
obsen ed. 

Percussion induce- pain. 

The tooth is very sore to the touch; 

occlusion in mastication or ordinary 
shutting of the teeth produce- pain 
irrespective of I henna! ohangi 

Carious defect-, as such, are of no con- 
sequence. 

The mandibular lymph nodes A. B, I ' or 

1) are swollen, tender and painful on 

pressure. 




Fio. 52, s.h. malic drawing of the relationship of the submaxillary and the sub- 
mental lymph nodes to the teeth of the upper and the lower jaw. A, />' an 



naxillary lymph nodes; I) - submental lymph nodes. 



The final diagnosis Is based on the observations obtained from b 
careful comparison of all the elucidated facts and usually leads to 
a diagnosis by exclusion. Its interpretation results in the pi 
nosisj and the final goal <>t* all clinical procedures, the treatment of 
the existing disease. 



CHAPTER VI. 
HYPERSENSITIVE DENTIN. 

Hypersensitive dentin may be defined as a state in which the 
exposed dentin of a vital tooth is painfully responsive to mechanical, 
chemical, thermal or electric irritation. The primary cause must 
be always attributed to its exposure to an irritant. Absence of 
enamel or otherwise pathologically exposed dentin are the neces- 
sary initial conditions essential for its occurrence. Enamel, which 
normally protects the dentin of the crown, may be absent as a 
sequence of incomplete calcification or it may be lost through 
pathologic processes, i. c, caries, erosion, abrasion or trauma, while 
the exposed dentin of a tooth root is primarily brought about by 
premature or senile atrophy of its protective alveolar process and 
its cementum. 

Pathology.— Before entering upon a discussion of the pathology of 
hypersensitive dentin, the anatomy and physiology of normal 
dentin should be briefly recalled. Dentin is made up of about 72 
per cent inorganic salts, about 10 per cent water and an organic 
colloidal matrix constituting the remaining percentage. The den- 
tin is traversed by a very large number of tubules measuring about 
1.5 to 5 ji in diameter, and radiating from the pulp cavity more or 
less wave-like toward the periphery, where they branch off, forming 
a deltoid network. Roemer has counted from 25,000 to 30,000 
dentinal tubules within the area of 1 sq. mm. The tubules are 
filled with lymph and with the protoplasmic processes of the odon- 
toblasts, as originally described by Koelliker, and they are known 
at present as Tomes' fibers. These fibers are structureless threads 
and are continuous through the full length of the tubules and their 
branches. Physiologic normal dentin has no sensation; its vital 
protoplasm transfers tactile impressions, thermal changes and 
chemical or electric irritation to the pulp. 

The so-called innervation of dentin is still a much mooted ques- 
tion. Professor Hopewell-Smith interprets its present status as 
follows: 

It is an interesting and important fact that it has not yet been 
proved to the entire satisfaction of all observers that nerve fibers 
exist in the dentinal tubes. Thus, there is a wide difference in 
men's views as to the innervation or non-innervation of the dentin. 
One school of belief, headed by Poll, Morgenstern, Roemer, Depen- 



^ DISEASES OF THE DENTAL n LP 

dorf, F. Boedecker, Kritzsch and Howard Mummery endea/or to 
explain sensitiveness t<> the occurrence of peripheral nerve fibers 
in the dentinal tubues, while the other school denies the existence 
of nerve fibers in this tissue. Among the names of those included 
in this group arc those of Retzius, Koelliker, Tonic-. Huber, Walk- 
hoff, Gysi and Hopewell-Smith. By persistent search in teeth of 
mammals and reptiles n<> definite nervous system has been demon- 
strated, the nerve fibers terminating in arborizations around the 
odontoblasts on the surface of the dental pulp. 

Impulses are carried through the dentin to the pulp, via the 
contents of the dentinal tubules, i. e. t dentinal fibrils the peripheral 
processes of the odontoblasts and lymph. There is an abundance 
of protoplasm in these innumerable channels. Members of the 
second school of thought are divided in their view 9 as to the causes 
of sensation. The hylopathist ascribes it to abnormal movements 
of the molecules of the dentinal fibrils while the others claim that 
demarcation currents, convection and osmosis are responsible for 

pain. All, however, are agreed that the cerebrospinal nervous 

system has no share in its production beyond that in the dental pulp. 

Personally, the writer is in full accord with the concepts 
of the second school of histologists, i. c, the non-inncrvation 
hypothesis of dentin. From a pharmacologic point of view lie is 
able to furnish sufficient data to substantiate this assumption. 
Basing his own conception upon this hypothesis, he assumes that 
hypersensitive dentin denotes a state in which the contents of the 
dentinal tubules are pathologically altered. This change is brought 
about by external physico-chemical influences which interferes 
with >urfacc tension, adsorption (inhibition) and diffusion. All 
processes arc closely allied phenomena. 

According to Gibbs' law, all substances which lower the 
surface tension of a solvent become more concentrated in the 
surface film than in the interior. It is a phenomenon which depends 
upon the increase of attraction of the molecules in the surface film 
for one another and puts the film under pressure. Thereby a 
hydrostatic pressure i> created which materially increases the 
normal osmotic pressure. As a rule, inorganic neutral silts, and 
many sugars very slightly raise the surface tension, whereas acids, 
b;is<-> and most organic substances lower the surface tension. The 
colloids concentrated in the surface film become very viscous, 
finally forming a membrane insoluble in water. Colloidal solutions 
readily adsorb water and dissolved silts from the surrounding 
medium. The adsorption of water increases, proportionally with the 

concentration of the salt Solution to a certain point and thereby 
an increase in the internal pressure of the colloidal solution is 

obtained. 
Surface tension is constantly trying to reduce itself; in a uniform 



HYPERSENSITIVE DENTIN 89 

fluid this is impossible while in a mixture consisting of two or more 
substances, which in themselves possess different surface tension, 
the lighter fluid has a tendency to collect on the surface of the 
more tense fluid. Under the influence of these different forces, 
dynamic equilibrium is established within a certain time. 1 These 
various factors favor mechanical adsorption or imbibition, reduc- 
tion of surface tension, increase of solubility under pressure and 
compressibility of water. It is interesting to observe that alcohols, 
fatty acids, esters and many organic solvents are readily adsorbed. 

Chemical adsorption is of less interest in this connection. The 
most important factor which influences adsorption is the ion con- 
centration of a fluid. The equilibrium of a phase relative to its 
ion concentration is controlled by the law of mass action. 

The relative viscosity of a fluid plays a most important role. 
If the surface of a solution adsorbs a dissolved substance the vis- 
cosity of its surface may markedly increase. As a consequence, 
albumins, soaps, saponins, dyestutt's, etc., form surface films which 
materially interfere with the dift'usibility, as compared to pure 
water of dissolved substances. 

When the colloidal contents of the dentinal tubules become 
exposed to the fluids present in the oral cavity, their surface tension 
become altered by adsorption and diffusion in accordance with the 
above enumerated physico-chemical processes; they become over- 
distended and thereby exert pressure upon the underlying odonto- 
blastic cells. The fluids in the tubules cannot be compressed, as 
water possesses no elasticity; it represents a rigid column which 
transmits pressure in the form of motion undiminished in all direc- 
tions. Any additional pressure which is exerted upon the over- 
distended surfaces is at once transmitted to the nerve filaments 
located at the surface of the pulp (the plexus of Boll), i. c, the 
anatomic threshhold of sensation. 

Cutting the enamel does not produce painful sensation. As soon 
as the amelo-dentinal junction is reached marked pain is usually 
experienced by the patient. Beneath the amelo-dentinal junction 
are located the interglobular spaces of Czermak which are com- 
pletely filled with semifluid protoplasm. Pressure and heat pro- 
duced by the revolving bur upon a relatively large surface area of 
fluid in this region are quickly transmitted to the pulp and hence 
pain is felt. Within the area of dentin which lies beyond this 
borderline zone sensation again is lessened until the advancing bur 
reaches within close proximity of the pulp. In carious dentin 
excavation of the zones of complete disorganization and of decalci- 

1 Decrease in surface tension is readily demonstrated by the following simple 
experiment: To 100 cc of absolute alcohol contained in a graduated cylinder add 
100 cc of distilled water. After equilibrium is established the mixture measures only 
about 192 cc at room temperature. 



90 



DISEASES OF THE DENTAL PULP 



fication does not produce sensation because the contents of the 
tubules are destroyed. As soon as the /.one of torpidity is reached 
again marked pain is manifested. Here the contents of the exposed 
dentinal tubules are subjected to Intense irritation brought about 
by acidity and other products of bacterial metabolism. The 
surface tension of the fluids in the tubules is markedly altered, hence 
the quick response to pressure and thermal influences. Below this 
/one of turpidity, the "translucent /one" of Tomes is observed in 
chronic caries. This tranducency of dentin is the product of a 
vital reaction. The chronic irritation of the odontoblasts causes 
the pulp to promptly respond by depositing adventitious dentin 
within the lumen of the tubules which necessarily lessens their 




I i,.. :,:; Sections of a carious tooth: '. enamel; '/. <l<'iitin: <■'/. carious dentin; '/'/, 
decalcified dentin; :>. Bone <>t' turbidity; i:. translucenl aone. (Photomicrograph by 
Hopewell-Smith. 



diameter in varying degrees or even produces complete obliteration. 
Hence, a smaller surface of the tubular contents is exposed to the 
advancing bur and. consequently, lessened sensation is felt. The 
gradual reduction of surface area of the dentinal tubules is a physio- 
logic process in the lite cycle of a tooth, hence sensitiveness dimin- 
ishes with advancing 

Mechanically abrated teeth or those subjected to the as yet 
little known process of erosion are rarely hypersensitive in the 
hitter states. Abrasion and erosion arc usually intensely chronic 

processes, hence their very slow progress offers to the irritated 

odontoblasts sufficient time to deposit adventitious dentin within 

the tubules and thereby protect the underlying pulp from further 



HYPERSENSITIVE DENTIN 



91 



irritation. Sections of mechanically or chemically abrated teeth 
containing living pulps always show a translucent zone. 

As stated above, the process of removal of enamel of a sound 
tooth by cutting and grinding, if done under proper precautions to 
avoid undue heat, is usually not painful. The freshly exposed 
dentin is relatively free from sensation. Within a short lapse of 
time, however, usually within twenty-four hours, this exposed 
dentin is excruciatingly hypersensitive. The exposure of the 
contents of the tubules to the fluids of the mouth as explained 
above, changes the surface tension so as to cause pronounced irrita- 
tion of the odontoblastic cells. 




54. — Silver nitrate applied to 
carious dentil) upon the living tooth in 
the mouth. Low power. 



Dehydration of the over-distended tubules by physical means 
relieves the hypertension; consequently, such an agent as warm 
air reduces the sensibility. Alcohol, potassium hydroxid or similar 
hygroscopic chemicals act synchronically as dehydrants and caus- 
tics. Self-limiting caustics as silver nitrate, superoxol, etc., super- 
ficially destroy the vitality of the protoplasmic fibers, and they 
protect the contents of the tubules by solid plugs of precipitated 
albumin. The disturbing elements are thereby permanently 
excluded from reaching the dentin. The disarranged equilibrium 
of the tubular fluid readjusts itself in a short time and consequently 
hyperesthesia is relieved. A substantial illustration of this fact is 
furnished by immediately protecting artificially exposed dentin 
with a coating of silver nitrate or a temporary cap set with gutta- 
percha and not with an irritating cement. Such dentin will exhibit 
no particular sensation at any time after the operation. 



92 DISEASES OF THE DENTAL PULP 

A 1 1 \ general condition which lowers the normal psychic reaction 
nf a patient as a whole naturally also Influences the reactivity of 
the tooth pulp. Therefore, such disturbances as acute nasal 

catarrh, influenza and other infectious diseases, exanthematOUS 

fevers, Increased Intradental blood-pressure, menstruation, anemia, 
genera] debility or certain neuropathic condition-, as neurasthenia, 

may leave their imprints upon the pulps in the form of congestive 
hyperemia and, consequently, any irritation of the exposed dentin 
of a tooth under these conditions is prone to exhibit indirectly 
excessh e sensibility. 
Prom the above discussion of its pathology, the writer concludes 

that hypersensitive dentin designates a state of irritation of the 

odontoblasts of the vital pulp. Irritation Is produced only by 

external audits, /. /•., physico-chemical processes induce changes in 

the surface tension (hypertension) of the exposed contents of the 

tubules. The increased reactivity of the disturbed equilibrium 
transmits any additional physical or chemical Impulse at once via 
the Tomes' fibers to the congested odontoblastic cells covering 
the pulp and which are in direct contact with the nerve fibers of 
the plexus of Boll, /'. c, the anatomical threshhold of sensation. 

Symptoms and Treatment. —The principal subjective symptom of 
hypersensitive dentin consists in more or less severe pain which 
is usually elucidated by marked temperature changes, chemical or 
electric irritation or mechanical interference of the exposed dentin 
surface'. Thermal irritation is (prickly and profoundly manifested 
by cold; 68° F. (20° C.) or below leave painful impressions, while 
heat, even up to 110° F. (60° C.) are often unnoticed. Chemical 
irritation results principally through an increase of surface ten-ion 
osmosis or by dehydration. Many foodstuffs, especially condi- 
ments, contain substances belonging to this group, among which 
fruit acids, salt and sugar play a most important role. Occasion- 
ally, electric shocks arising from contact of opposing metals, i, , .. 
an amalgam filling and a gold crown, etc., elicit painful Impressions. 

Mechanical irritation brought about by use of instruments during 

dental operations, and rarely from the application of external 

Forces, is probably the most common source of interference with 
the exposed dentin sin-face, due manifested pain i> not continu- 
ous; it merely lasts as long as the irritant is present. The patient 
is always able to point to the affected tooth. Inspection may 
reveal a carious or other defect of its crown, an exposure of its 
root or frequently an incomplete union at the periphery of the 

enamel and eeinentuin at its neck. The thermal test with hot 
and, especially cold water, it!* pressure exerted by an instrument 

placed upon the exposed dentin surface, is very pronounced. 
< Changes in the color of the tooth, percussion, palpation and roent- 
genogram are negative. Hypersensitive dentin offers good chances 



HYPERSENSITIVE DENTIN 93 

for conservative treatment; under proper management it may 
readily be eradicated. 

The rational principle of treatment should be based on the 
recognition of its pathologic cause, i. e., hypertension of the con- 
tents of the dentinal tubules. Any method or means which favors 
the readjustment of the altered colloidal equilibrium and prevents 
further irritation of the exposed dentin surface is useful for the 
purpose. 

In general the remedies employed should conform to the following 
requirements: 

1. The remedy must not injure the organic or inorganic con- 
stituents of the tooth. 

2. The remedy must not permanently interfere with the welfare 
of the pulp. 

3. The administration of the remedy must not require a com- 
plicated instrumentarium. 

4. The pharmacologic action of the remedy must be exhibited 
within a few minutes. 

5. The remedy must be readily applicable to all classes of cavities 
with regard to their location. 

6. It must not produce pain. 

7. Permanent discoloration of dentin must not occur. 

For convenience, we may divide the applied remedies into: 

A. Physical and chemical procedures: 

1. Keen-edged instruments. 

2. Caustics. 

B. Local and general remedies: 

1. Local anesthetics and sedatives. 

2. General anesthetics and sedatives. 

Sharp Instruments.— The superiority of sharp instruments as 
compared with dull ragged-edge tools when working upon living 
tissue is generally recognized by e very-day experience. Sharp 
excavators cut without much pain when employed with a definite, 
precise movement at right angles to the long axis of the tubules. 
Dull engine burs produce heat by friction and by being held in 
contact with the cavity wall too continuously. They should not 
only be sharp, but run at high speed and allowed to touch the 
surface very lightly as they revolve. A thin coating of vaselin 
further reduces undue friction. 

Caustics.— Caustics are substances which destroy living tissue by 
virtue of their coarse chemical or physical action. This action may 
manifest itself by abstracting water from albumin, by dissolution 
or precipitation of the albumin, by oxydation or by substitution. 
Caustics which are employed for the purpose in view are principally 
dehydrants and albumin solvents or precipitants. Alkalies con- 
taining hydroxy 1 groups— KOH and XaOH— are very powerful 



!i| VISE [SES OF THE DEh TAL PULP 

albumin solvents and they arc not self-limiting. The albumin 
precipitants are primarily represented by the metallic Baits, by 
certain organic compounds as phenol, alcohol, etc., and l>y heat. 
Mineral acids should not be applied on living tooth structure for 
such purposes. The precipitates obtained by metallic salts differ 
widely in regard to their density; silver nitrate, for instance, 
produces a dry dense scab, while zinc chlorid combines with the 
albumin to form a loose Qocculent clot. 

A- we have stated above, hypertension of the contents of the 
dental tubules is the primary cause of hypersensitive dentin. 
The removal of this tension will necessarily interfere or pre 
the transmission of impulses; hence the simplest and mos1 logical 
method of reducing hyperesthesia of dentin for the purpose of 
excavating is to dispel the moisture from the tubules. It has been 

found that desiccation of a cavity by subjecting it to ;i current of 
warm air in conjunction with absolute alcohol will bring about a 
condition of immunity to sensation in proportion a- -\\<\\ desiccation 
is thorough or partial. 

Bencyl alcohol, also known commercially as phenmethylol, 
possesses the combined properties of acting as a local anesthetic 
and a dehydrating agent. It may l>c employed in pure form or in 
t he following combination: 

Bencyl alcohol 50 parta 

Chloroform ■ '>" " 

Alcohol 20 w 

To best accomplish desiccation of the dentin the rubber dam 
should he adjusted to the tooth and the greater portion of the 
carious mass is carefully removed with spoon excavators; the 
cavity should he bathed with absolute alcohol 1 and then subjected 
to a stream of warm air applied in some convenient manner. 
The ordinary air syringe or chip blower may have its point heated 
in a (lame, and then by forcing the air in the hull) slowly through 
the tube a jet of warm air will he delivered in the cavity. By 
holding the nozzle of the syringe at the proper distance, and having 
learned by experience how much heat to apply, one can often 
inject a current of air into the cavity at ncarh the same tempera- 
ture a- that of the tooth; hut if the air when it reaches the cavity 
should he either perceptibly above or below the proper temperature 
pain will he produced. In some warm-air syringes the tube is 
provided with a hollow receptacle somewhere along it^ length, 

which, when heated, raises the temperature of the air within it before 

being directed into the tooth cavity. Neither of these methods i^ 

\ t . ~< .1 1 1 r r- alcohol for this purpose may be prepared by adding either | ounce 
anhydrous copper sulphate <>r an equal quantity of well-burned unslaked limi 
ounces <>f commercial alcohol. 



HYPERSENSITIVE DENTIN 95 

at all exact, and they are therefore liable to produce more or less 
pain in the act of dehydration. A better plan is to employ a 
syringe in which a coil of fine platinum wire is contained within 
the orifice; this coil is connected by wires through the body of 
the syringe with a source of electric current; in operation the 
resistance encountered by the current of electricity passing through 
the platinum coil heats it and maintains a steady temperature. 
Air forced over this coil and through the nozzle, especially air 
supplied from a receiver and under pressure that can be controlled, 
may be heated to a temperature that will approximate very closely 
that of the tooth, and therefore produce little or no pain. If 
the air passing from the nozzle of the syringe should be too warm 
it can be modified by holding it a little farther away from the 
tooth, or if not warm enough, more heat will be delivered when 
it is held in closer proximity. 




Fig. 56. — Electric warm-air syringe. (Guilford.) 

An instrument of this character with a compressible blub instead 
of an air supply from a receiver is represented in Fig. 56. The 
operation of desiccation should not be hurried; time must be 
allowed for raising the air to a suitable temperature, so as to cause 
as little pain as possible. In addition, the operation should be 
continued until the dentinal walls of the cavity have become 
perceptibly lighter in color, indicating that they have been robbed 
of their moisture. If desiccation is not carried to this point it will 
fail in its effectiveness; but, if the moisture has been removed from 
the dentin to a considerable depth, as it may be if desiccation be 
sufficiently continued, sensitiveness will have become nearly or 
entirely obliterated. Whether we depend entirely upon dryness 
to relieve hypersensation of dentin or not, it should always be 
resorted to, for it proves a most valuable preliminary means where 
it is to be followed by medication of any kind. 

Caustic alkalies are preferably applied in the well-known form of 
Robinson's remedy which is composed of equal parts of potassium 



90 



DISEASES OF THE DENTAL PULP 



hydroxid and crystalline phenol, forming potassium phenate when 
triturated together in a warmed mortar, with the addition <>t' a 
small quantity of glycerin to render it plastic. It should be pre- 
preserved in well-stoppered bottles. Another serviceable appli- 
cation consists of an intimate mixture of I part of <r> stalline sodium 
carbonate and 5 parts of potassium carbonate. It produces a 
past} mass which must be kept in a tightly corked bottle. A 
small quantity of these compounds applied to the previously dehy- 
drated painful dentin surface and rubbed into it with a warm 
burnisher will often prove to be of benefit. The caustic and 
dehydrating effect of these agents combined with the warm air 

blasl lowers hyperesthesia markedly; their benumbing action. 
however, is only superficial and they have to be repeatedly applied 
as the preparation of the cavity progres 

Albumin precipitants are principally represented by silver 
citrate, zinc chlorid and phenol. The silver sail acts very super- 
ficially and very slowly. Incidentally, by combining with the 
chlorin present in the albumin and in the presence of light it pro- 



NOZZL£ THfHTADED EAS/CY ffEMO VEO FOR STEM- /Z//VG 



\ 



PETA INING META L 




Fig. •">-. Sterile warm-air syringe. 



duces a jet-black discoloration of the involved dentin. On all 
exposed dentin surfaces, especially on the exposed root- of the 
posterior teeth where the resultant color is no objection, it is an 
admirable desensitizer. It is best applied as a freshly prepared 
saturated aqueous solution. Other silver salts are of less value in 
this connection, as they are less caustic. It should be remembered 
that the pharmacodynamic action of silver nitrate depends upon 
the precipitation of albumin by the nitric acid ion and ru t upon the 
silver ion. The Litter merelj combines with the albumin, forming 
;i complicated double salt, i. e. t silver-albumin chlorid. which in 
the presence of light is partialh reduced to ;i black oxid. Zinc 
chlorid is an admirable desensitizer; its application in crystal 
form or as a saturated solution is somewhat painful on account 
of it- acid reaction. As it is not self-limiting, it should not l>e 
applied into deep— cited cavities on account of the danger of pulp 
irritation at the time of its application or subsequently. Liquefied 
phenol does not penetrate deepl> into tooth structure and may be 
safely applied to cavities of an\ depth. When applied into a 



HYPERSENSITIVE DENTIN 97 

dehydrated cavity in conjunction with the warm air blast it pro- 
duces quick and marked superficial benumbing effects, hence it is 
widely employed for this purpose. The addition of local anesthetics 
to phenol for this purpose, i. e., cocain, etc., is an irrational procedure. 
Within the last few years Buckley has lauded dry formaldehyd 
(trioxymethylene) in the form of a paste as: "A new, safe and 
reliable remedy for hypersensitive dentin." This empirically com- 
pounded paste contains approximately 35 per cent of dry formal- 
dehyd rubbed up with vaselin and a few minor substances of no 
direct value. International dental literature of the last decade is 
filled with references relative to the use of formaldehvd as a 




Fig. 58. — Photomicrograph of a longitudinal section of a healthy tooth treated in 
the mouth with a protoplasm poison and a vital stain. The pulp was vital as ascer- 
tained by the electric current. At a, a cavity was drilled and a small quantity of 
formaldehyd desensitizing paste containing 1 per cent of methylene blue was sealed 
into it for three days after which time the electric current revealed a dead pulp. 
Between a and b the bluish-green stain indicates the path of the formaldehyd on its 
way through the dentinal tubules into the pulp, at c the coronal portion of the latter 
is also stained. As methylene blue only stains dead dentin it closely followed the 
formaldehyd on its devilatizing passage through the tubules into the living pulp. 

desensitizing agent and all writers, except Buckley, agree that it is 
a most dangerous agent for this purpose, as it will injure and, in 
most instances, kill the pulp. It produces numbness of dentin in 
the same manner as arsenic, only acting somewhat slower. Tri- 
oxymethylene acts as a non-self-limiting caustic which penetrates 
comparatively quickly through any thickness of dentin. As an 
illustration of the intense caustic action it may be stated that in 
the hands of some practitioners the Buckley desensitizing paste 
constitutes the routine application for the purpose of destroying 
the pulps in deciduous teeth. The same deleterious results are 
obtained with the so-called " Norwegian Dentin Anesthetic." This 
7 



OS 



DISEASES OF THE l>i:\ TAL PULP 



compound contains carpain and paucin, two alkaloids which aci 
somewhat like erj throphlein, L e. t they kill the pulp. 

Occasionally protoplasm poisons arc recommended for the pur- 
pose of desensitizing dentin. In many instances these drugs arc 
erroneously referred to as caustics. A protoplasm p<»i-«»n should 
l>e designated as ;i drug which endangers, or even kills, living-cell 
structure without visible changes. Protoplasm poisons are not 

self-limiting in their action. Arsenic trioxid and, to a less extent, 
the alkaloids ncr\ ocidin, erythrophlcin and paucin are the principal 
substances of this group that have been employed as desensitizing 



Denti 




Odontoblasts 



Nerve bundles 



I i... .".". Section of a tooth treated with Buckley's desensitiring paste. Pulp shows 
extensive necrotic areas Dear point of application. 1 1 temisch. I 



agents. Arsenic, when applied even in the very minutest quan- 
tities, will usually always kill the pulp, as its action cannot be 
controlled. This is equally true of the above named alkaloids; they 
have only historical interest at present. 

Local Anesthetics mid Sedatives. True local anesthetics, i. *.. 
cocain or its substitutes when applied t<> exposed sound dentin 
without pressure do not produce any pharmacologic effects. Even if 
sealed into ;i Fairly deep-seated cavity in which the underlying 
dentin i> not decalcified, no effect is obtained. Living protoplasm 
reacts unfavorably against the ready absorption of substances i»\ 
endosmosis for two reasons: l ! I The albumin molecule i^ rela- 



HYPERSENSITIVE DENTIN 99 

tively very large and is not easily diffusible; and (2) it possesses, 
as an integral part of its life, vital resistance toward foreign bodies. 
According to Hertwig, protoplasm primarily transfers irritation 
and secondarily, transmits absorbed materials. Therefore, the 
anesthetic solution has to pass through the entire length of the 
dentinal fibers before the nerve tissue of the pulp proper is reached. 
Consequently, a certain period of time is required before the physi- 
ologic effect of the anesthetic is manifested and the period of this 
latency is dependent on the thickness of the intermediate layer of 
dentin. The migration of a protoplasm poison through dentin may 
be actually observed by adding a vital stain to it, as, for instance, 
methylene blue added to arsenic or dry formaldehyd. The time 
required for its passage through about 5 mm. of sound adult dentin 
is from twenty-four or more hours. The pharmacodynamic power 
of a drug depends upon its reaction with the living protoplasm 
through the catalytic action of ferments. The decomposition of 
the absorbed drug occurs comparatively quickly, usually within 
minutes. These observations are seen daily on injecting anesthetics 
or other solutions hypodermically. An average hypodermic dose 
of cocain is completely decomposed by the ferments of the proto- 
plasm within the period of an hour, i. e., its typical local anesthetic 
effect is manifested within a few minutes after the injection. The 
anesthesia remains at its height for some thirty minutes and from 
there on it diminishes until by the end of the hour fairly complete 
recovery of normal sensation has reoccnrred. Therefore, if we 
apply cocain to sound dentin it is decomposed on its passage over 
the Tomes' fibers and before it reaches the threshhold of sensation, 
i. e., the nerve plexus at the surface of the pulp and hence no anes- 
thesia is produced. The nature of the cocain salt, i. e. t whether 
is a hydrochloric!, a nitrate or a lactate, has no bearing upon its 
therapeutic action. The apparent results obtained with these 
cocain salts must be attributed to the preliminary dehydration, 
protection of the exposed dentin by a temporary filling, etc., and 
not to its therapeutic effects. This is equally true in regard to 
most of the heterogeneous mixtures of cocain with other substances, 
as, for instance, potassocain, vapocain, etc. Again, in the widely 
recommended solution of cocain (alkaloid) in chloroform and ether 
the cocain base plays no part. The apparent result obtained are 
produced by the process of "evaporating to dryness" and thereby 
obtaining a marked reduction in temperature which is the obtun- 
dent factor. When cocain or its substitutes are forced into the 
living protoplasm of the unobstructed dentin tubules under pres- 
sure, its anesthetic action is manifested within a few minutes. The 
vital resistance of protoplasm is readily overcome by compara- 
tively slight force which quickly transfers the anesthetic solution 
by an increased osmotic interchange to the surface of the pulp. 



11)0 DISEASES OF THE DENTAL PULP 

The phenomenon is to be explained as an anesthesia obtained by 
intimate contact under pressure, either mechanical or by electro- 
motive force (cataphoresis). The pulp of a tooth and consequently 
the dentin may be completely desensitized by any one of the well- 
known methods of contact anesthesia, by using hand pressure or 
that derived from a dental hypodermic syringe or some other more 
complicated apparatus or by electricity. 

Electrical Endosmosis. Some years ago cataphoresis was much 
lauded for the purpose of desensitizing dentin. This process con- 
sists in placing a concentrated solution of COCain on cotton in the 
sensitive cavity, and having it carried along the dentinal tubules 
toward the pulp by means of a galvanic current, i. e. t l>\ electro- 
motive force. A battery is employed with the negative electrode, 
the cathode, inserted in the cavity, and the anode placed upon some 
pari of the patient's body, as the hand, etc. The current carries 
the cocain via the Tomes' fibers into the pulp and anesthetizes it. 
While in this condition, which usually lasts for an hour or more. 
the tooth may be worked upon without any pain. For a while 
this method met with great favor because of the perfect results 
obtained, but it was found to l>c a very slow process, requiring a 
cumbersome apparatus and often consuming more time than the 
operator had at his command, and occasionally requiring a second 
application in order to produce complete anesthesia, hence at present 

it has been largely discarded. 

Of the numerous essential oils which have been suggested as 
obtundents of dentin, oil of clove stands out prominently. It- 
pharmacologic action depends on the presence of eugenol, an 
unsaturated aromatic phenol. The basic constituent of eugenol 
coiisi>t- of para-amino-benzoic acid, a body which as such does not 
exhibit any marked therapeutic effects. Its methylester, anes- 
thesin is an efficient local anesthetic; however, it is only slightly 
soluble in water. Einhorn and Uhlfelder, taking anesthesin as a 
base for their synthetic research, finally succeeded in preparing 

para-aniino-ben/.o\ l-diethyl-amino-cthanol, commercially known as 

novocain or procain, which at present is the most efficient substitute 

for cocain. 

Essential oil-, in general, possess marked penetrating power. 

However, upon a fairly thick layer of sound dentin they are of 
little value when employed as obtundents. A different pharma- 
codynamic action is observed with arsenic. Arsenic trioxid, 
\ (). in the presence of certain ferments of living protoplasm, 
i. i.. oxydases and catalases, is changed to the pentoxid, A-n. 
which again is quickly reduced to the trioxid. This perpetual 

oxidation and reduction within tin- protoplasm of the cell can 

violent oscillation of the molecule of active oxygen and thereby 
it- therapeutic effect is manifested. The metalloid arsenic merely 



HYPERSENSITIVE DENTIN 101 

plays the role of an autoxidizer. The presence of the absorbed 
arsenic can be detected in the tissues by chemical analysis, that of 
absorbed cocain cannot. 

Among the local sedatives refrigerant anesthetics should be 
mentioned. These agents lower the temperature, diminish sen- 
sation and reduce the volume of the parts to which they are applied. 

Physically reducing hyperesthesia of dentin by the application 
of cold is best accomplished by employing a chemical which has a 
low boiling point. Pure ether (boiling point, 95° F. [35° C.]), free 
from water, produces good results. Certain other hydrocarbons 
possess similar properties in varying degrees, depending on their 
individual boiling point. Pure ethyl chlorid (boiling point, oo° F. 
[13° C.]) is best suited for our purpose, as it lowers the temperature 
of the tissues sufficiently to produce a short superficial anesthesia 
in a few minutes. Too rapid cooling or prolonged freezing produce 
deep anesthesia, but such procedures are dangerous; the circulation 
in the pulp may be cut off so completely as to produce death. 
Liquid nitrous oxid, liquid carbon dioxid and liquid air, all of 
which have boiling points far below zero, are recommended for 
such purposes, but they require cumbersome apparatus and some 
of these agents are extremely dangerous to handle. 

In general, it should be stated that the application of cold for 
the purpose of obtunding hypersensitive dentin is a barbarous 
procedure. The initial pain produced by the cold is in many 
instances most intense and much more pronounced than that 
experienced by cutting the untreated dentin. 

Indirectly, hyperesthesia of dentin may be completely eliminated 
by locally blocking the sensory nerve fibers leading into the pulp 
of the respective tooth. Any one of the well-known methods or 
combination of methods, i. e. y infiltration and conduction anes- 
thesia, are available for this purpose. On an average, most satis- 
factory results in a single tooth are obtained by using the peri- 
cemental injection provided the pericementum is sound. 

The paralyzation of the central end-organs in the brain by a 
general anesthetic will naturally also anesthetize all the tooth 
pulps. Nitrous oxid is possibly more often used for this purpose 
than other anesthetic agent. The much lauded "analgesia" of a 
few years ago was, as might have been expected, a failure. With 
the improvement in the various methods of local anesthesia, general 
anesthesia for this specific purpose has lost much of its former 
significance. 

The control of hypersensitive dentin by the administration of 
narcotics or sedatives is rarely called for. Of the general sedatives, 
the bromids are usually recommended. Large continuous doses 
are required to manifest their action as they impair the perception 
of sensory stimuli only to a very mild degree. Average doses of 



102 DISEASES OF THE DENTAL PI LP 

morphin require at least one-hall hour before a depression of the 
sensory impulse is manifested, while chloral hydrate shows a marked 
lowering within ten to fifteen minutes. Moiphin-scopolamin 
administered hypodermicaflj causes mosl pronounced general 

narcotic effects and. of COUTSe, marked lowering of the sensory 

reaction of the pulp. 

Sensation in a tooth may he experimentally measured by passing 
a weak electric induced current through it and the above data are 
based upon observations obtained by such measurements. 

BIBLIOGRAPHY. 

Walkhoff: Dee Sensible Dentin, L890. 

Gyed: Schweiserische Vierteljahresschrift fuer Zahnheilkunde, 1901. 

Ostwald: Colloid Chemistry, Philadelphia, 1919. 

Bechhold: Colloids in Biology and Medicine, New Xbrk, 1918. 

Michaelis: Lehre von der Adsorption in Loesungen, Berlin, L909. 

Prins: Dental Cosmos, August, 1915. 



CHAPTER VII. 
THE EXPOSED HEALTHY DENTAL PULP. 

The modern treatment of a wound from a surgical point of view 
centers about two primary objects— the removal of all necrosed 
tissue and establishing asepsis. Clinically, all wounds must be 
looked upon as being infected. If the infection is not restricted 
to the surface, but has penetrated into the deeper structures, 
drainage and antiseptics are employed. 

An exposed healthy pulp, which in reality is a wound, must always 
be looked upon as being infected. In conformity with the difficul- 
ties as elucidated in a previous chapter regarding the treatment of 
an infected pulp the normal surgical aspect of the operation is com- 
pletely upset. The prime requisite for any interference with the 
dental pulp is based on a thorough knowledge of its anatomic 
relationship to the surrounding wall of dentin, i. e., a recognition of 
the constant change within its own body during the life cycle 
of the respective tooth. 

In many instances the unintentional opening into the pulp 
chamber is avoidable. If it does occur it is primarily caused by 
unhappy circumstances or by an atypical structure of the pulp, 
and in the hands of the experienced operator these accidents are 
to be classed as comparatively rare occurrences. The density and 
not the color of the involved dentin is the safest guide to follow T 
during the process of excavating the cavity. It is to be under- 
stood that the tooth is always placed under the rubber dam. Care- 
ful inspection of the cavity with sterile explorers and a magnifying 
glass is indispensable. Sterilization of the cavity with a suitable 
antiseptic lessens the danger of accidental infection. If the pulp 
is exposed direct access offers a greater chance for its conservative 
treatment than an inaccessible cavity; in the latter instance the 
operator should lose no time in devitalizing the pulp. If the pulp 
is still covered with a protecting layer of dentin an effort should be 
made to preserve this covering provided the diagnosis of the respec- 
tive condition of the pulp justifies such a procedure. These cases 
are treated as outlined under "Hyperemia of the Pulp." 

"Pulp-capping," as this process of applying a protective medium 
to the exposed pulp is technically known, will always remain, 
relatively speaking, even under the very best possible conditions 
an operation of chance. Nevertheless, the writer cannot subscribe 



10 1 DISEASES OF THE DENTAL Pi LP 

to the supposed authoritative statements of certain practitioners, 
namely, thai pulp-capping is always ;i failure. 

The practice of capping an exposed pulp was first attempted and 
successfully carried out by Philipp Pfaff, 1 of Berlin, in L756, 
although Fauchard, in 1728, had described a method of placing 
a filling into a cavity in which he found an exposed pulp without, 
however, making a special effort to protect the delicate organ by 
a suitable covering. Pfaff employed a cap made of ,«_:« >1< 1 foil suffi- 
ciently large to cover the exposure and carefully burnished the 
edges over the sound dentinal wall. A suitable filling was then 

delicately placed over the capping. A detailed description of the 

practice of capping exposed pulps is recorded by Leonard Koeker 1 
in L826. This procedure, as described by the famous international 

operator a century ago, is so very interesting that it i^ here appended 
in outline: " I hope I may he permitted to detail my own method 
of operating in cases where the nerve of the tooth has become 
exposed, which 1 have practised for upward of thirteen years with 
much satisfaction and success. I require for this the following 
apparatus: 

"1. A small iron wire, fastened to an ivory handle. The extrem- 
ity of this w ire 1 file to the size of the exposed Mirface of the nerve, 
and bend the wire in such a direction as to enable me to touch the 

exposed part of the membrane without touching any other part of 
the tooth or the mouth. 

"2. A thick tallow candle with a large wick. 

"I direct my patient to discharge all the saliva he may have in his 

mouth, and then to incline his head backward against the head 
supporter of my operating chair. I put the candle into his left 
hand and direct him to hold it in such a position that the flame of 
it may he on a level with his mouth, and about 8 inches from it. 1 
now place myself on the right side of the patient, and holding his 
lip- sufficiently open with my left hand to prevent the instrument 
from touching them, 1 again dry the cavity as perfectly as possible 
with a lock of cotton fastened to the point of the cauterizing wire. 
Having effected this, I throw away the cotton from the extremity 
of the wire and make it red hot in the flame of the candle. With 
the wire thus heated. I touch the expo-ed part very rapidly, -" 

that it- surface contracts without, however, suffering to it penetrate 
deeply into the nerve or to touch an\ part of the bony structure, 
a- tin- would inevitably bring <>n suppuration and destruction of 

the whole lining of the inetiil >ra ne. The bleeding spot must be 
touched very quickly with the hot wire, which i- sometimes neces- 
sary to he repeated two or three time- hefore the part- are Suffi- 

1 A,bhandiung \<>n den Z&hnen des menschlichen Kdpera und deren Krankheiten, 
Berlin, L766. 

I tenia! Sin L '< r.\ . London, 1826. 



THE EXPOSED HEALTHY DENTAL PULP 105 

ciently contracted. The wire should be perfectly red hot, for in 
this state the cautery acts suddenly, and almost entirely without 
pain, but when heated to any temperature short of that of red 
heat much pain and inflammation are generally produced. This 
operation is indeed so slightly painful that I have been solicited 
by my patients to repeat it, although they had required much 
persuasion to induce them in the first instance to suffer its applica- 
tion. It, however, must be performed very adroitly, and without 
any loss of time. To prevent the flow of saliva to interfere, the 
patient must be desired to close his lips, but to keep his mouth wide 
open, until the whole of the operation is finished, which he is capable 
to do for a certain time only. 

"The nerve, which before cauterization has a fleshy appearance, 
is after this operation like a black point. I take care not to disturb 
this point, for if the black scar is removed a new wound will be 
formed and bleeding again will ensue; but I leave the future heal- 
ing altogether to Nature, and only caution my patient against using 
such things as might interfere with its salutory operations. Having 
thus far removed all possible cause of future disease and irritation 
in order to prevent any unnecessary exposure of the nerve, by which 
inflammation and destruction of it might be produced, I now 
terminate the operation by fulfilling the third indication, that is, to 
protect the nerve against injurious impressions from without by 
filling up the cavity of the tooth with metal. Having again per- 
fectly dried the cavity, I now take a small plate of very thin lead 
leaf and lay it upon the exposed nerve and on the immediately 
surrounding parts. I next carefully fill up the whole cavity with 
gold." 

This very same procedure was advocated as a new venture by 
Szabo in 1902. 1 

TREATMENT OF THE EXPOSED HEALTHY PULP. 

Definition.— A break in the continuity of the pulpal wall of a 
tooth and thereby esposing its pulp. 

Etiology.— Exposure of a pulp may be caused by a trauma, such 
as a fracture of the tooth, cavity preparation, etc., or it may occur 
as a sequence of pathologic disturbances, i. e., caries, erosion, abra- 
sion, corrosive acids, etc. The former accidents usually reveal a 
sound pulp, while in the latter cases an infection of the pulp may 
be expected. The term "partially exposed pulp," which is occa- 
sionally employed to designate a condition in which the intervening 
layer of dentin is very thin, is a misnomer, as the pulp is not exposed. 
In reality all clinical exposures of the pulp are partial in their nature, 
as the pulp is never exposed in its entirety. 

1 Oestcrreich-ung. Vicrteljahresschrift fur Zahnheilkunde, 1902, p. 368. 



106 DISE iSES OF THE l>i:\ TAL PI LP 

Indications for Capping a Healthy Exposed Pulp. The indica- 
tions For "capping" a healthy pulp, i. e., covering of the exposed 
pulp with a protective aseptic material, may be summarized as 
follows: 

1. Only perfectly healthy exposed pulps which are not, or are 
niil\ very slightly, wounded offer suitable cases for this operation. 
A health} exposed pulp has a pink color; an Inflamed pulp appears 
as ;i bluish-red pulsating tissue, trying to protrude through the 
broken pulpa] wall. 

2. The healthy pulps of temporary or permanent teeth whose 
roots an- not fully completed offer the best chances for capping. 
Pulp growth denote- functional activity, i. e. t physiologic hyper- 
emia, hence such pulps exhibit marked properties of repair. 

:;. The pulps in the teeth of advanced adults and those pulps 
which show signs of degeneration are not suitable for capping. 
The latter usually undergo atrophic changes and are read} to 

succumb at the slightest provocation. 

1. Pulps iii fully formed teeth exposed by caries, erosion, abra- 
sion, etc., and those lacerated by the revolving engine bur, should 
never be capped. 

Pathology.- An exposed pulp practically always denotes infection. 
The control of an infection of the exposed pulp does not lie within 
the power of the operator; as yet, there are no remedies at our 
command which will eradicate an infection without producing 
some injury to the delicate structure of this organ. In doubtful 

cases the safest policy is always to devitalize at once. 

The strict observations of the following prerequisites as applied 
to the operation of pulp-capping will govern its ultimate success: 

1. A correct diagnosis. 

2. Ready accessibility to the exposure. 

:;. Asepsis of instruments and of the field of operation. 

I. Careful protection of the exposed pulp against drying out and 

future infection. 

."). 'The application of a suitable aseptic capping material with- 
out the slightest pressure. 

Pulp-capping Materials.— The materials advocated tor the pur- 
pose of capping exposed pulps vary greatly; the more important 

one- are: 

1. Depressed metallic disks or foil made of platinum, gold, lead. 

etc. 

2. All dental cements with the exception of the silicates, prefer- 
ably zinc oxysulphate cement I Fletcher's artificial dentin). 

:;. (iutta percha in substance or in solution. 

l. Mixtures of zinc oxid with thymol, phenol, oil of do aol 

Iodoform, etc. 
;.. Various substances, i e. s cork, asbestos, rubber dam. paper, 



THE EXPOSED HEALTHY DENTAL PULP 



107 



mica, celluloid, paraffin, glutol (formaldehyd-gelatin), etc., either 
as such or medicated or in combination with an adhesive. 

6. Numerous proprietary preparations. 

A pulp-capping material should possess the following properties: 

1. It must be non-irritating. 

2. It must be a non-conductor of temperature. 

3. It must be readily adaptable and applicable without the 
slightest pressure. 

4. It must be non-putrefactive. 

The rationale embodied in the process of pulp-capping consists 
in applying an inert aseptic cover over the exposed pulp to protect 
it against further irritation. In due time the pulp usually slightly 
shrinks away from the break; secondary deposits of dentin which 
were supposed to take place according to former observers do not 
or onlv very rarelv occur. 




Fig. 60.— Exposed healthy pulp capped with a paste of eugenol and zinc oxide, 
a, connective tissue forming a cicatrix: 6, splinter of dentin; c, newly-formed secondary 
tissue. (Baetwyler.) 



In conformity with these requirements, the selection of a suit- 
able pulp-capping material is a comparatively simple matter. 
Many of the substances advocated, especially caustic antiseptics 
and certain cements, are directly harmful. During the "setting" 
of many of the cements of the oxyphosphate type a high degree of 
heat— in some instances 140° F. (60° C.)— is evolved, which tem- 
perature invariably kills the pulp (p. 554). Such compounds as 
formaldehyd, zinc chlorid, phenol, creosote, eugenol, etc., when 
applied pure or in concentrated solutions, are caustics, and will in 
most instances destroy the pulp in due time. Even the repeated 



ins 



DISEASES OF THE DEh TAL PI LP 



application of such ;i mild remedy a^ oil of clove to the <-\] >«»-<■< 1 
pulp will eventually cause its death. The statement is frequently 
made that ;in exposed pulp under a formaldehyd preparation or a 
zinc oxychlorid cement filling will remain quiescent. A pulp 
treated with these substances when subsequently examined will, 
in the majority of cases, be found dead. The resultant aecrosed 
tissue ;it some future period usually will become infected. 




Fig. 61. Placing <-;q> over pulp exposure. 

Treatment. As stated above, strong antiseptics must be rigidly 
avoided; the very delicate pulp is too easily injured by most of 
these compounds. A pellet of cotton moistened with a weak 
dichloramin-T solution is placed gently over the pulp exposure to 
act as a protective against infection, but primarily to prevent its 
drying out. Irreparable shrinkage will occur if this phase of the 
operation is overlooked. The cavity is prepared with sterile hand 
instruments, the cotton pellet is removed and the cavity is dried 
with a fresh piece of sterile cotton, hut never with the warm air 



c 3]: :■ 



I'm. 82. — Watson's metal pulp caps. 

blast. A hit of pulp-capping material, consisting of _' part- of zinc 
o\id and 1 part of thymol, 1 i- taken Up with a warm suitably shaped 
instrument, carried to the edge of, hut not upon, the exposure and 
with a warm amalgam plugger the material which has become 

plastic by the heat of the instrument is molded \ er\ gently and 

without the least pressure over the opening. The operator, espe- 
cially the beginner, i- cautioned against the use of a large quantity 



\ suitable pulp-capping may It prepared a- follows: 'Mm- part <>f thymol is 
melted in a porcelain capsule and mixed with 2 parts of dry sine oxid. The mixture 
id on a glass slab and on oooling it is removed and preserved in a well-stop] 



THE EXPOSED HEALTHY DENTAL PULP 109 

of capping material. Only enough should be employed to cover 
the exposure and its edges. The capping sets almost immediately. 
Many operators prefer to apply the capping upon a depressed 
metallic disk, ^uch disks may be obtained from supply houses, or 
they may be readily made by burnishing a thin piece of metal 
(aluminum) with a ball-shaped instrument against a stick of soft 
pine wood. The adjacent dentin is now sterilized with a 50 per 
cent thymol solution in aceton or alcohol and the cavity is then 
coated with a hard copal varnish. After drying, the cavity is 
lined with a veneer of oxyphosphate cement. The cavity may then 
be occluded with a gutta-percha preparation or some other tempo- 
rary filling material for further observation. 



CHAPTER VIII. 
HYPEREMIA. 

Synonyms. Acute, active, arterial, congestive or physiologic 
hyperemia and chronic, passive, venous, obstructive or pathologic 
hyperemia of the dental pulp (hyperemia pulpce). 

Definition. Hyperemia denotes the presence of an increased 
amount of blood in the pulp. It may be of a physiologic or a 
pathologic type, and partial or total in its nature. Physiologic 
hyperemia indicates an Increased influx of blood, while pathologic 
hyperemia results from a retarded afflux. 

Etiology.- Hyperemia of the dental pulp is the initial response 
of this tissue to an irritation. Only the pathologic type Is of 
interest to us at this moment. Agents which favor sudden tem- 
perature changes, as carious detects, erosion, abrasion, etc., play 
a most important role. The late I )r. (t. V. Black always emphasized 
the fact that: Hyperemia is very commonly the result of heat gen- 
erated in polishing fillings, either by rapidly revolving disks, or by 

the vigorous drawing of tape hack and forth on the approximal 

surfaces of the teeth. Large metal fillings or metallic inlays are 
excellent conductors of heat and cold and when inserted into 
deep-seated cavities arc common causative factors of irritation 
from thermal shocks. Preparing a sound tooth for a shell or 
jacket crown by grinding its enamel and dentin and setting the 
crown with an oxyphosphate cement usually produces a very 
severe hyperemia which may lead to the death of the pulp. Electric 
shocks as a sequence of contact between an electro-positive metal. 
i. /.. an amalgam filling, and an electro-negative metal, as a gold 

CTOWn, f<»r instance, with an interposed electrolite. i. c, saliva, and 

thus forming a completed circuit, arc frequently observed. These 

electric shocks at limes produce spasms of acute pain. 

During severe damp cold weather, cases of obscure idiopathic 

hyperemia of the pulps of the upper and. less SO, of the lower teeth 

are frequently observed, These acute manifestations of pain are 
secondary disturbances and should be classified a- borderline 

diseases Of the teeth and their adjacent structures. 

Disturbances of the vasomotor system of the bloodvessels of the 
pulp brought about l>\ direct or indirect irritation of these vessels 
i- the primary cause of hyperemia. 

Varieties. Clinically, onlj the pathologic type, i c obstructive 
venous) hyperemia is observed. Acute hyperemia of a physiologic 



HYPEREMIA 



111 



type plays no part in our discussion; if it is caused by an irritant 
it is of very short duration and usually disappears with the removal 
of its cause. 

Clinical Pathology.— The clinical picture of hyperemia of the pulp 
is portrayed by a patient complaining about a recent disagreeable 
sensation in a tooth, especially toward morning. Hot and princi- 
pally cold fluids, or even a breath of cold air, produce a more or less 
sharp pain. The tooth may have been recently filled, or a cavity 
or some other form of structural defect of its enamel surface may 
be present. In the aged, senile atrophy of the alveolar process 
frequently exposes the roots of posterior teeth, which in consequence 
become highly sensitive to thermal changes. 




Hyperemia <>f dental pulp. 



Pathologically, hyperemia in its chronic form is the most fre- 
quently exhibited type of pulp lesions; it is the progenitor of 
practically all acute or chronic diseases of this organ. The hyper- 
emic pulp, except in traumatic cases, is always covered with a 
more or less sound layer of dentin. During the later stages of 
caries, when this layer becomes softened, infection of the pulp is 
practically always to be expected. Chronic irritation of the pulp 
leads to a renewed activity of its odontoblasts, resulting in the 
deposition of calcium salts. Within the sound dentin these addi- 
tional deposits produce the translucent zone of Tomes, i. e., a 
partial calcification of the dentinal fibers. When confined to the 



I 12 DISEASES OF THE hl-:\ TAL PULP 

])iilp proper the deposition results in adventitious dentin along the 
walls of the root canal and In pulp nodules within the body of this 
organ. Pressure from these deposits may lead to painful acute 
or chronic irritation and often to complete atrophy of the pulp. 
Hyperemia of the pulp, histologically, manifests itself in the dila- 
tation of all bloodvessels. As long as circulation continues the pulp 
will live. The anatomic structure of the pulp doc- not favor the 

establishing of collateral circulation; hence, if the circulation 

becomes completely obstructed stasis occurs which quickly leads 
to its death. 

Subjective Symptoms. On taking hot and especially cold fluids 
in the mouth, or from a breath of cold air, an unpleasant sensation 
is felt or it may manifest itself as a paroxysm of sharp pain lasting 
for some seconds or a minute or two only. 

Diagnosis.— The patient is always able to point to the affected 
tooth. The antecedent history accompanied 1>\ an inspection may 
reveal a recent filling, a shallow cavity or some other defect of the 

crow ii, or an exposure of the root. The pulp is not exposed. The 
temperature test with cold water or the ethylcblorid spray is quite 
positive, while changes in the color of the tooth, percussion, palpa- 
tion and roentgenogram arc usually negative. The hyperemic pulp 
shows a slight increase in its reaction to the faradic current. 

A differential diagnosis between simple irritability and pathologic 
hyperemia may be readily established. If a pulp which has dis- 
tinctly responded to cold water resumes its normal equilibrium 
when the tooth is again surrounded by the physiologic fluids of the 
oral cavity the disturbance should be classified as simple irritability. 
If, on the other hand, the pain or even an unpleasant sensation lasts 

for some minutes thereafter, we are entitled to speak of the condition 
as pathologic hyperemia. 

Prognosis. Hyperemia of the pulp in its early stages usually 
roponds favorably to conservative treatment. Under proper 
management resolution will occur in most cases. 

Treatment. The basic principle of the treatment of hyperemia 
of the pulp consists in the removal of the irritant, i. c, interposing 
a non-conductor between the focus of irritation and the outside 
source. In mild forms, suitable preparation of the cavity, its 
sterilization with a concentrated (50 per cent) solution of thymol 
in aceton or alcohol, the application of a quick drying hard cavity 
varnish to act as an insulator, and occluding the cavity with cement 
cither as ; i final filling or as an intermediate step prior to the inser- 
tion of a metal plug, is usually crowned with SUCCess. Severe cases 

require the application of antiseptic drugs sealed into the cavity 
with a temporary filling material. A gutta-percha preparation or a 

cei i nut of the oxysulphate t \ pe Fletcher's artificial dentin) or Pro- 
tein cement is most convenient for this latter purpose. The selec- 



HYPEREMIA 113 

tion of a suitable antiseptic is largely a matter of choice. Oil of 
clove, pure or camphorated liquid phenol or chloro-phenol, creosote, 
thymol, etc., either singly or combined answer the purpose well. 
All of the enumerated agents exhibit, as a side action, local anes- 
thetic and incidentally astringent properties. Existing pain which 
is the sequence of an irritation will be automatically eliminated by 
the eradication of its cause. The medication should remain in the 
tooth for twenty-four hours, and, if need be, it may be renewed. 
If a more efficient sedative compound is desired a saturated solution 
of chloretone in oil of clove deserves to be recommended. 

Medicaments should not be sealed into a tooth in a haphazard 
manner in regard to time. Usually the medicament becomes 
exhausted in about twenty-four hours and must be renewed if 
further action is to be expected. To avoid disagreeable thermal 
shock from sealing a medicament in a deep-seated cavity it should 
always be slightly warmed prior to its insertion. After the pulp 
has resumed its normal activity the cavity is finally sterilized, 
varnished and filled as described above, preferably with cement 
only, for a suitable length of time for observation. 

Distressing cases of hyperemia of the pulp are represented by 
those teeth in which, through senile atrophy of the alveolar pro- 
cess, a large part of the root is continuously exposed to thermal 
change's and to irritation by foodstuffs. The palatine roots of the 
upper molars, and less often the roots of the lower molars, are 
primarily represented by this group. As these exposed roots are 
not amenable to protection by a filling, the only therapeutic measure 
which promises relief is the application of silver nitrate in a con- 
centrated solution. The soft tissues surrounding the exposed root are 
protected by a coating of vaselin or a napkin, and the root itself is 
dried with cotton and warm air. A very concentrated solution of 
silver nitrate may be quickly made by crushing a few crystals on 
a glass slab and adding a few drops of distilled water. With a thin 
spatula-shaped stick of orange wood dipped into the solution, the 
entire area is thoroughly coated, and if possible the tooth root is 
exposed to direct sunlight for some minutes, or by reflecting the 
light into inaccessible places with the mouth mirror. In due time 
an intense black color is obtained. Silver nitrate may be more 
quickly reduced by using a 1 per cent solution of potassium or 
sodium hydroxid in distilled water. The treatment must be 
repeated two or three times on alternating days until a jet-black 
color of the exposed dentin is obtained. If some of the silver solu- 
tion should accidentlly come in contact with the soft tissues a 
concentrated solution of sodium chlorid should be applied at once. 
Sodium chlorid is the chemical antidote of silver nitrate and changes 
it to an insoluble silver chlorid. 

The removal of enamel from a healthy tooth by grinding, etc., 
8 



II J DISEASES OF Till-: DENTAL PULP 

preparatory to attaching a shell or .'picket crown, in most instances 
produces a very painful reaction, i. e., an obstructive hyperemia oi 
its pulp. If the operator decides not to destroy the pulp it must 
\ )V protected prior to setting the crown with cement against the 




1 ,,, ,,i Hyperemia of the pulps of the upper teeth caused by senile atrophy 
f the alveolar process and the cementum and exposure ol the dentin. The 
exposed dentin has been treated about twice a year on two to three visjta witn a 
concentrated solution of silver nitrate and has kepi the patienl free bom pain 
during a period of five years. 

future irritation of this vehicle, otherwise its death in due time is 
almost certain to occur. A heavy coating of silver nitrate until a 
jet-black color is obtained, as described above, and coating the 
black stump with a suitable hard varnish will restore the hyperemic 

pulp to its normal activity and protect it against future irritation. 



CHAPTER IX. 
ACUTE SIMPLE PULPITIS. 

Synonyms.— Acute simple inflammation of the dental pulp, idio- 
pathic pulpitis, traumatic pulpitis, pulpitis acuta simpler, pulpitis 
idiopathica, pulpitis traumatica. 

Definition. — An acute partial or total exudative (destructive) 
inflammation of the unexposed pulp. 

Etiology. — Acute inflammation of the pulp is primarily caused 
by bacterial invasion, usually a streptomycosis of a mixed type, 
arising as a sequence of existing dental caries. Numerous other 
primary and secondary conditions, however, which have been dis- 
cussed in detail under the subject of "Etiology," play important 
roles as etiologic factors. 

Varieties.— Clinically, only one variety is observed, /'. c, acute 
pulpitis. Depending on its etiologic nature, clinicians occasionally 
refer to this disease by such specific terms as idiopathic or trau- 
matic or toxic pulpitis, etc. The disease may manifest itself as a 
partial or a total pulpitis; the clinical differentiation between these 
two forms, which are purely quantitative and not qualitative 
concepts, is too hazy to permit of a distinctive diagnosis. Partial 
pulpitis probably always precedes the total involvement of the pulp. 

Clinical Pathology.— The clinical picture of acute simple pulpitis 
is usually readily recognized from a description of the manifested 
pain as subjectively experienced by the patient. The tooth, in 
most instances, shows a carious defect or some form of deep-seated 
abrasion and can always be pointed out by the patient; in cases of 
idiopathic pulpitis the correct location of the involved tooth becomes 
more difficult. The pulp is not exposed except in certain traumatic 
cases. 

Pathologically, acute simple pulpitis portrays the typical picture 
of an acute inflammation; it is always the sequence of a neglected 
obstructive hyperemia and is primarily caused by a bacterial 
invasion. It should be borne in mind, however, that an inflamma- 
tion may be produced by purely mechanical (pulp nodules), thermal 
(rapidly revolving disks or "setting" of certain oxyphosphate 
cements) or chemical (arsenic) irritation without bacterial infec- 
tion, and that aseptic inflammation with aseptic pus may be the 
result. The routine manifestations as they gradually develop dur- 
ing the inflammatory process in ordinary soft tissues, as previously 



16 



[SI - OF THE DENTAL PULP 



discussed, must of necessity also take place in an inflamed pulp 
with this vital difference that in the latter instance the cardinal 
symptoms of inflammation with the exception of pain cannot be 
or arc only rarely observed in a tooth in situ. It should be borne 
in mind that a pulp maj become diseased and may die without 
manifesting the slightest sensation. Atrophy of the pulp, which, 
however, is not an inflammatory process, frequently brings about 
such changes. 

In very rare cases a pulp may die as a sequence of some general 
diseases, as leukemia for instance, without manifesting any pain. 
Sclerotic nerve degeneration as it occurs in locomotor ataxia occa- 




imple pulpitis 



sionally produces complete anesthesia of the dental pulp and sub- 
sequent painless inflammation and death. These disturbances arc 
discussed under the subject of "Secondary Pulpitis." 

In the earl} stages of acute inflammation only that part of the 
pulp, usually a horn, which is located opposite the point of infec- 
tion, becomes involved. Consequently, the initial picture repre- 
sents a partial pulpitis. 1 depending upon the severity ^\' the infec- 
tion, the inflammation spreads more or less rapidly, and a total 
pulpitis with its numerous pathologic peculiarities is the chron- 
ologic sequence of the intensely acute process, finally resulting in 
suppuration. 

Acute partial pulpitis in verj rare instances terminates in reso- 
lution; in the majority of cases suppuration and gangrene arc the 



ACUTE SIMPLE PULPITIS 



117 



logical sequences. With the involvement of the apical tissues a 
long chain of secondary disturbances may be expected. 

Subjective Symptoms.— The pathognomonic symptoms of an acute 
pulpitis are the spontaneous manifestation of pain occurring espe- 
cially in the evening and at night, and its increase on the application 
of cold. The gradation of the severity of the pain and its duration 
differentiates the two types of pulpitis, i. e., the partial and the 
total variety. In the partial type the painful paroxysm may last 
for some minutes; the tooth is always located by the patient and 
no reflex disturbances are observed. The total involvement of the 
pulp gradually produces an increase in the painful symptoms in 
regard to the length of its intervals and of its duration; the location 
of the involved tooth becomes progressively more difficult and 




Fig. 66. — Acute simple pulpitis. A magnified section of Fig. 65 showing the 
early stages of inflammation of a horn of this pulp which is located opposite the 
point of infection. 



reflex disturbances are manifested. With the increase of the inflam- 
mation there is also to be observed a gradual diminishing painful 
response to the application of cold, while heat becomes progressively 
more and more intolerable. 

Diagnosis.— The painful tooth, as pointed out by the patient in 
the early stages of the disease, usually shows a carious defect or a 
traumatic lesion. On removal of the debris from the cavity, a 
layer of discolored and more or less decalcified dentin is observed 
covering a horn of the pulp The lightly passing explorer is not 
felt. On exerting pressure upon the decalcified pulpal wall a quick, 
painful response is obtained. Cold water produces a marked 
paroxysm of acute pain. A pledget of cotton saturated with 50 
per cent alcohol and placed into the cavity produces severe painful 



lis DISEASES OF THE DENTAL PI LP 

irritation which ceases on its removal. The color of the tooth is 
not altered. Percussion in the early stages of the inflammation is 
negative; in the last stages of total pulpitis, when the infection 
has passed into the periapical tissues, tapping the tooth with a 
steel instrument brings forth a painful response. Transillumina- 
tion and roentgenogram are negative. The faradic current pro- 
duces a marked sensory response from the diseased pulp which is 
far below the normal irritation point of the patient, indicating an 
acute inflammation. The more severe the inflammation, the less 
current is required. 

The last stages of an acute total pulpitis frequently produce most 
violent paroxysms of pain which may radiate over a large area 

of the face and may last for many hours. The pain IS materially 

exacerbated on lying down and in many respects it may simulate 
facial neuralgia. With the death of the pulp, the pain usually 
ceases unless the pericementum should have become involved. 

A correct diagnosis of idiopathic pulpitis is usually fraught with 
great difficulties. In many instances the tooth shows no apparent 

extrinsic disturbances, although the true etiologic factor of tin- 
type of pulpitis, /. e. } the growing pulp nodule, i> much favored 
by mechanical causes, among which advanced cases of abrasion 
predominate. A roentgenogram may reveal pulp nodule- which. 
as stated, are always present, and thereby differentiate idiopathic 
pulpitis from hyperplasia (exostosis) of the cementum of the 
involved tooth. The pain, as described by the patient, is of a 
severe, acute, throbbing and lancinating character, and during the 
paroxysm, which lasts for a minute or two, the affected side of the 
face become- flushed. The general character of the pain closely 
simulates trifacial oeuralgia from which, however, it may be readily 
differentiated. Pathologically, idiopathic pulpitis represents a type 

of true neuritis of the dental pulp. It is claimed that when a 

tooth responds very intensely on percussion or the application of 
cold eth\ 1 chlorid) during a cycle of pain, and this In persensation 
passes oil' immediately after the paroxysm ceases, idiopathic pul- 
pitis is to be suspected. It- pathognomonic signs are pulp nodules; 
unfortunately, the roentgenogram does not always reveal their 
identity . 

In most cases of traumatic pulpitis the pulp is exposed; rhythmic 
pulsation and a deep bluish-red color are observable manifestations 

of an acute inflammation. If the exposed pulp i- pricked with a 

pointed instrument, a few drop- of dark venous blood flow from 
the wound and the existing pain is much eased. 
'The quick response of the inflamed pulp to a low faradic cm-rent 

and the acute lancinating pain produced by the application of cold 

water diagnosticallj differentiates acute simple pulpitis from other 
types. 



ACUTE SIMPLE PULPITIS 119 

Prognosis— A well-established acute simple pulpitis always offers 
an unfavorable prognosis for the preservation of the involved pulp. 
The peculiar anatomic structure and other characteristics of the 
latter tissue, as discussed in the preceding pages, do not favor 
resolution. The conditions which justify an attempt to conserva- 
tively treat an inflamed pulp may be summarized by stating that 
only the very earliest stages of acute partial pulpitis should be 
selected for such procedure, provided that the particular pulp is a 
young growing pulp. The destruction of the pulp is always indi- 
cated in cases of total pulpitis, of severe iodiopathic pulpitis and of 
practically all cases of traumatic pulpitis. 

Treatment.— The indications for the respective therapeutic meas- 
ures depend largely upon the decision of the operator as to whether 
an attempt should be made to conservatively treat an inflamed 
pulp, or whether it should be destroyed at once. Consequently 
the mode of treatment selected for each procedure necessitates a 
separate discussion. In both instances the initial preparation is 
the same, i. e., the tooth is placed under the rubber dam, the cavity 
is excavated, sterilized and a sedative antiseptic is sealed into it for 
twenty-four hours, and if need be, repeated. If resolution of the 
pulp is anticipated, the future steps are exactly the same as out- 
lined under the "Treatment of Hyperemia of the 1 )ental Pulp," i. e., 
the prepared cavity is sterilized, varnished, and finally covered 
with cement with a view to further observation. In case the pulp 
is to be devitalized, the initial treatment, as referred to above 
(which should never be neglected), is followed by the surgical or 
therapeutic devitalization proper, i. c, local anesthesia as a pre- 
liminary procedure is instituted or arsenic is sealed into the cavity. 
Both methods are discussed under the caption " Devitalization of 
the Dental Pulp." The removal of the pulp in a case of idiopathic 
pulpitis does not require any further discussion; it is precisely 
the same as indicated above. 



CHAPTER X. 
ACUTE SUPPURATIVE PULPITIS. 

Synonyms. Acute suppuration of the dental pulp, purulo-gan- 
grenoua Inflammation of the dental ]>nl p, pulpitis acuta purulenia 
sru purulo-gaitgrcenosa. 

Definition. An acute suppurative (destructive) inflammation of 
the exposed pulp accompanied by the formation of abscesses or 
phlegmonous infiltration. 

Etiology.— In the greatest majority of cases it is brought about 
by an infection from organisms connected with the carious pro< 
i. e. t a mixed streptomycosis, although secondary infection from a 
chronic suppurative pericementitis or hematogenous causes are 
occasionally observed. Suppurative pulpitis is usually restricted 
to filled teeth of the permanent set, i. c, teeth in which at the time 
of placing the filling a minute break in the continuity of the pulpal 
wall has been overlooked or where an infected layer of decalcified 
dentin covering the pulp has been inefficiently sterilized. 

Varieties.— Clinically, only one variety Is known. It manifests 
itself as an acute type, although a subacute, chronic or a purulo- 
gangrenous form are occasionally observed. The line of demarca- 
tion between these various grades is too hazy to be determined 
clinically with any degree of satisfaction. 

Clinical Pathology.- The clinical picture of a case of suppurative 
pulpitis is always typical. The patient Suffers excruciating, intol- 
erable pain. In fact, tin* pain is so intense that it may be classified 
with the severest forms of suffering to which human flesh is heir to. 
The pain is not localized and i~> of a violent boring, throbbing 
character, corresponding to the rhythmical beating of the pulse. 
The affected tooth cannot be pointed out by the patient, and it 
may even be Impossible for him to designate the jaw in which it is 
located. In Hie last stages of severe cases general symptoms, such 

;i> chills and U'vcv or marked weakness due to loss of sleep, and to 

suffering, etc., accompany the local manifestation. 

Pathologically, purulent pulpitis typifies a circumscribed suppu- 

ration of the pulp, i. e., an abscess. The abs< ess may be single or 
multiple. The circulation is much obstructed, since the Infected 
pulp has lost all power of defence; the progressive obstruction 
finally results in a circumscribed stasis and death of the necrobiotic 
portion of the pulp. 'I he vessel walls break down; polynuclear 



ACUTE SUPPURATIVE PULPITIS 



121 



leukocytes, and, to a less extent, red corpuscles, are attracted 
toward certain bacteria in enormous quantities and thereby become 
the progenitors of pus corpuscles. A circumscribed collection of 
this freshly formed pus is designated as an abscess. In its early 
stages the abscess is usually confined to a horn of the pulp and is 
located directly opposite the point of entry of the infection, namely, 
the minute opening into the pulpal covering. Above the abscess 
a wall of inflamed tissue denotes the line of demarcation, and 
the remaining pulp presents the typical picture of a severe acute 
inflammation. With the progressive advance of necrobiosis, the 
final submission of the whole pulp to the infection is only a question 
of time. It should be observed that the process of destruction is 
in most cases intensely acute. The nerve fibers preserve their 
integrity to the Aery end of the struggle. As the pulp is confined 




Fig. 07. — Acute suppurative pulpitis. 



within an unyielding wall of dentin, the increasing pus produces 
compression and irritation of these fibers, and hence the persistent 
intolerable pain. 

If the pus does not remain localized, but infiltrates the spaces 
between the connective-tissue cells, a phlegmonous suppuration of 
the entire pulp results which quickly kills it. Through the agencies 
of specific proteolytic ferments the necrosed tissue changes to 
gangrene. In multi-rooted teeth, especially the molars, this purulo- 
gangrenoug type of pulpitis is most frequently observed. In such 
cases one root canal may be found to be totally gangrenous, while 
another canal may contain a pulp remnant in an advanced state of 
severe acute inflammation. 

Subjective Symptoms.— Very violent, throbbing, continuous pain, 
increasing on entering a warm room, on lying down, or on the 
application of heat. Cold applied to the tooth does not seem to 



122 DI8E iSES OF THE l>i:\ TAL l'i LP 

affecl it \<t\ much. Slowly Increasing, persistenl pain usually baa 
been present for man\ hours or even days. 

Diagnosis. On inspection of the oral cavity, one should alwa; - 

be suspicious of a filled tooth of the permanent set as being the one 
involved. Its color is usually not altered. Transillumination may 
Furnish a diffused shadow picture of the coronal portion of the 

pulp. On applying beat a marked increase of pain is felt, while 

cold iii many instances seems to palliate temporarily. This symp- 
tom is typically pathognomonic of suppurative pulpitis. Percus- 
sion, especially in the later stages, indicates an involvement of the 

peridental meinl>rane; there is no swelling of the gum tissue. 

Roentgenogram is usually negative. The resistance to the electric 
current is materially lessened, i. e. t the amount of current necessary 
to bring about a response is much higher than that which is required 
to establish the normal irritation point of the patient. By care- 
fully inspecting the pulpal wall of the excavated cavity a minute 
break in its continuity or an exceedingly thin elastic layer of decal- 
cified dentin is usually observed. 

Differential Diagnosis. The intensity and duration of the throb- 
bing pain and its increase on applying heat or by any other means 
which raises the blood-pressure differentiates suppurative pulpitis 

from other types. 

Prognosis. Resolution of a pulp affected with suppurative pul- 
pitis is not to be expected; its removal is indicated. r riie subse- 
quent treatment of the root canal, etc., usually restores the tooth 

to its normal functions. 

Treatment. -On penetrating into a pulp chamber containing a 
suppurating pulp with a bur, practically no pain is experienced; 
occasionally, however, a very short paroxysm may be observed. 
On withdrawing the bur, the pent-up pus wells up, followed by a 
drop or two of dark blood. The violent pain which the patient baa 
suffered for hours or days ceases almost instantly. The pulp 
chamber should be opened as widely as possible and washed out 

with tepid water. A broach may now he inserted to ascertain 
whether the whole or only a part of the pulp has SUCCUmbed to the 

infection. In tin* former case immediate extirpation of the necrotic 
pulp debris is indicated. A dressing of dichloramin-T is sealed 
into the empty root canal and the patient is dismissed with the 
general directions given below. The subsequent treatment of such 
root canals is discussed under "Necrosis and Gangrene.' ' If, how- 
ever, a part of the pulp is still alive, an effort is made to gently 
remove the necrotic portion until the line of demarcation is reached. 
Copious washing with tepid water will, by depletion, materially 
assist in quieting the intensely congested pulp stump. This 
antiphlogistic measure w ill be gratefully appreciated bj the patient. 
\ sedative antiseptic is now sealed into the dried pulp chamber 



ACUTE SUPPURATIVE PULPITIS 123 

for from twenty-four to forty-eight hours. Suitable compounds 
for such purposes consist of a saturated solution of chloretone in 
oil of clove or a 20 per cent solution of novocain in camphorated 
phenol. No effort should be made at this time to extirpate the 
remaining pulp stump under pressure anesthesia. Violent pain 
will always follow an attempt of anesthetizing an inflamed tissue 
by direct contact. Even conduction anesthesia in such cases is not 
always followed by its customary success. To apply arsenic upon 
an inflamed pulp indicates utter disregard of the fundamental 
principles of pharmaco-therapy; intolerable pain is always the 
sequence of such a procedure. On return of the patient the now 
quiescent pulp stump will usually allow its extirpation under some 
form of local anesthesia or arsenic application as discussed under 
"Devitalization of the Pulp." 

The general condition of a patient suffering with suppurative 
pulpitis demands careful attention. Light nutritious food is ad- 
vised, and the patient instructed to go to bed as soon as possible 
in order to refresh himself with a long and much needed sleep. 
Before retiring, as a prophylactic, 10 grains (0.6 gm.) of acetyl- 
salicylic acid (aspirin) are taken with a glass of water or a cup 
of warm tea. A saline purge given the following morning is in 
most eases indicated. 



CHAPTER XL 
SECONDARY PULPITIS. 

Synonyms. Secondary inflammation of the dental pulp, pulpitis 
secundaria. 

Definition. A secondary Inflammation of the unexposed pulp as 
a sequence of a local or a general disease. 

Etiology. Secondary pulpitis may be caused by a primary exist- 
ing local disturbance within the region of the affected tooth or by a 
genera] disease. In the majority of cases the causative agent Is 
the sequence of a local or general infection, although general disease 
of a non-infectious type, such as leukemia, locomotor ataxia, chlo- 
rosis, increased intradental blood-pressure and various neuropathic 
conditions, as hysteria, neurasthenia, etc., may be the exciting 
factors. 

Varieties. Clinically, secondary pulpitis may manifest itself a^ 
any one of the numerous varieties of pulpitis, i. e,, its course may 
run from an obstructive hyperemia to necrosis or gangrene of the 
pulp, although usually it is restricted to the hyperemic type. 

Clinical Pathology. The clinical picture of secondary pulpitis 
depends primarily upon the underlying disease and as a consequence 
it varies accordingly very widely indeed. If the primary disturb- 
ance of the pulp is of a purely local character the resulting secondary 
pulpitis may present itself as any one of the numerous modifications 
as outlined above and its early recognition should offer no difficulties. 
If, on the other hand, the underlying cause is a general dia 
the clinical picture becomes much diffused. The patient com- 
plains of pain, which he usually designates as being of a continuous, 

dull character. He is not able to locate the respective tooth, hilt 

merely points to the affected side of the face Mich disturbances 
usually manifest themselves as the early stages of obstructive 
hyperemia and they arc recognized from a description of the exist- 
ing pain. The teeth in most instances will he found to he intact. 

In certain rare cases necrosis of the pulp may exist, as in leukemia, 
increased intradental blood-pressure, etc.. which at times, through 
;i crack in the enamel mid dentin, becomes secondarily Infected 
and gangrene with it> numerous consequences results. These 
hitter disturbances are also readily diagnosed. In rare instai 
as in locomotor ataxia, the secondary pulpitis manifests itself by 
a total absence of sensation due to nerve degeneration or as a degen- 



SECONDARY PULPITIS 125 

eration of the entire pulp, and it may be discovered by accidentally 
or intentionally entering into the pulp chamber. 

Pathologically, secondary pulpitis manifests itself within the 
pulp by the same symptoms as they are observed in other tissues. 
If the underlying cause is an infection from a local source it is 
usually of a mixed type and as a consequence its pathology differs 
nowise from that discussed respectively under the primary disease 
of the dental pulp. If the secondary disturbance is dependent 
upon a general disease a discussion of the pathology of the latter, 
with the exception of the general facts, must be omitted at this 
moment. For a further elucidation of the subject the reader is 
referred to works on general and special pathology. 

Diagnosis.— Secondary pulpitis as a sequence of a primary local 
disturbance offers no difficulties in its recognition, and may be 
readily diagnosed by the various methods as outlined in the previous 
chapters. If the pulpitis is caused by a general disease an effort 
should be made to locate the predisposing disturbances. It is not 
to be assumed that the dental practitioner should boast as an expert 
diagnostitian of general diseases. Consequently the following diag- 
nostic hints are merely cited as aids to a possible recognition of 
the primary disease, but by no means as an indication for the 
treatment of the respective ailment. The patient should at once 
be intrusted to the eare of a general practitioner or a specialist for 
further observation. 

Of the general diseases which are prone to cause secondary idio- 
pathic disturbances in the pulps of the upper teeth preeminently 
acute catarrh of the maxillary sinus should be mentioned. It is 
of very common occurrence, indeed, and, with Arkcevy, 1 who has 
depicted the first clear clinical picture of the symptomatology of 
this disease, the writer is fully in accord that: One should not 
overestimate unimportant things nor neglect things which may be 
of great value. The ready recognition of the underlying antrum 
disturbances as the true cause of the existing dental ailment com- 
bined with the subsequent treatment which, incidently, is usually 
successful, is a source of satisfaction to both patient and operator. 
Hence, a detailed discussion of the clinical phases of this dental 
borderline disease may not be amiss. 

Acute nasal catarrh, "cold in the head,'' is an acute catarrhal 
inflammation of the Schneiderian membrane, which lines the nose 
and its accessory cavities. It is characterized by feverishness, 
feeling of discomfort in the head with a free discharge of watery, 
mucous or mucopurulent fluid. Acute nasal catarrh is principally 
brought about by an infection through sudden atmospheric changes, 
exposure of the face and neck or the feet and ankles to cold draught 

l Arkoevy: Oesterreich-ungar. Vierteljahresschrift, 1S97, p. 40. 



L26 



DISE ISE& OF THE DENTAL PULP 



and dampness are among the usual causes. Automobile rides In 
chill) moist air are most frequent sources. By continuity of the 
mucous lining of the aose an acute rhinitis or any other infection 
of a genera] character, such as influenza, pneumonia, scarlet f'< 
tuberculosis, measles, etc., rapidly spreads to the antral sinus. 
Anatomically, the maxillary sinus presents in its lower floor little 




I ongitudinal section of a premolar showing the diseased pulp. 
caused li\ inilui 11/..1. Fisch< 



hillock- which are the apical ends of the roots of certain upper 
teeth, t. '.. principally the molars and premolars. Frequently, 
these root ends protrude through the lower floor and are only 
covered bj the mucous membrane of the antral cavity. It is readily 
obser ed that an inflammation of this membrane which practically 
is synchronous in its blood and nerve supply with that of the 
adjoining teeth will rapidh spread to the pulp- of the teeth within 



SECONDARY PULPITIS 127 

the affected region. A dull painful sensation about the teeth and 
the bony region of the afflicted side of the face is the result. The 
patient cannot locate the painful teeth. On pressure upon the 
external wall of the antral sinus within the region of the canine fossa 
distinct pain is felt which may simulate a neuralgic paroxysm. 
The concomitant appearance of these symptoms points to a border- 
line disease of the teeth and the antrum and it should be diagnosed 
as an acute catarrh of the maxillary sinus and secondary obstruc- 
tive hyperemia of the pulps of the involved teeth. The disease 
occurs principally in heavy winter weather and is much aggravated 
by a simultaneously existing influenza. During the winter of 1917- 
1918 the writer observed among the ()50 students of the Evans Insti- 
tuge some 35 cases of this type, i. e. } about 5 per cent of the total 
number. The prognosis is always favorable. 

If by accident or otherwise a pulp is entered into and it is found 
to be free from sensation a differential diagnosis will clarify the 
situation in regard to its causative factors. Senile types of degen- 
eration (atrophy), locomotor ataxia or leukemia are the three 
primary diseases which may be responsible for this condition. 

Degeneration of the dental pulp is of a very common occurrence, 
especially in abrated and in senile teeth and it is readily diagnosed 
in the exposed organ. (See Degeneration of the Dental Pulp.) 

Locomotor ataxia is a disease principally observed in males 
of middle life. It originates in a chronic degeneration of the posterior 
columns of the spinal cord and the posterior nerve roots and is 
characterized by loss of coordination, neuralgic pains in the limbs, 
loss of sensation and trophic changes. The diagnosis is made 
positive by three pathognomonic signs: (1) Westphall's sign, i. e., 
absence of the patellar reflex; (2) Romberg's sign, i. e., swaying of 
the body and inability to maintain erect position with closed eyes; 
and (3) Argyll-Robertson's sign, i. e., loss of pupillary reflex to light. 
The prognosis is always unfavorable. 

The chronic degeneration of the nerve endings as an early symp- 
tom of locomotor ataxia is most interestingly demonstrated in the 
dental pulp and the peridental membrane. On entering into an 
apparently normal pulp of a patient suffering with this disease it 
will be observed that this ordinarily most sensitive organ will not 
respond to the advancing dental broach and it may be removed 
without the slightest manifestation of pain. Spontaneous painless 
loosening of sound teeth, principally of the molars and premolars 
of the upper jaw to an extent that they may be readily removed 
with the Angers, should always be looked upon as a pathognomonic 
symptom of an existing locomotor ataxia. Cases of this type 
should arouse grave suspicion and the patient should at once be 
put through the above-mentioned diagnostic tests. If they are 
positive he should immediately be referred to a physician. 



L28 DISE 18E8 OF THE DENTAL PULP 

Leukemia, usually an acute disease of the blood, manifests Itself 
in ;in enormous increase in the Dumber of white blood corpuscles, 
with enlargement of the lymph nodes, the spleen, etc In the 
mouth leukemia produces characteristic symptoms which are readily 
recognized 1>\ the trained observer. The gums are swollen, easily 
bleeding on being wounded, especially near the dental papilla-, and 
the palate is often covered with petechial spots of coagulated blood. 
The gingival tissue frequently exhibits necrotic areas and presents 
a dirty, brownish puffed-up ridge which loosely encircles the teeth. 
The secretion of saliva and mucus is much accelerated and foul 
breath is very pronounced. In other words, the picture presents 
a typical leukemic Stomatitis. An examination of the blood must 
be Insisted upon to verify the diagnosis of this comparatively rare 
disease. The prognosis is always unfavorable. 

Malaria, a paroxysmal fever, is characterized by a regular suc- 
cession of definite Stages, i. e. } cold, hot and sweating, and followed 

by a period of complete intermission. It is caused l>y a protozoon 
present in the blood, the Plasmodium miliaria*. When the char- 
acteristic chills, fever and sweat occur periodically the diagnosis 
i> practically certain, although a blood examination i- often desir- 
able. Plagg, Ware, Garretson and numerous other writers have 
called attention to the relationship of odontalgia (secondary pul- 
pitis) to malarial fever. Especially significant in this respect are 
the observations of Marshall. 1 He relates that: "It was my for- 
tune or my misfortune, I might say, to practice for many years in 
a malarial district, and I saw many cases of neuralgia arising from 
malarial influences, as proved by quinin in curing them without 
operation. I found pulpitis more difficult to control by the ordinary 
remedies in this district than I have found in any other place 
where I have practised. There seems to be a hypersensitiveness to 
nerve tissue in these cases, and the ordinary remedies for controlling 
pulpitis do not seem to have the same effect. Abscessed teeth do 
not re-pond to treatment as readily in Mich district- as upon high 
land where malaria is not present." The writer, from his own 
observations, i^ in full accord with Marshall's statement regarding 
the relationship between malaria and secondary pulpitis. In 
sections of the country infested with malaria one mould always 
be suspicious of a possible linking-up between malarial fever and 

i lol.t r\ pulpitis. 

Increased intradental blood-pressure constitutes a most interest- 
ing etiologic factor in the production of secondary pulpitis. The 
credit of having first called attention in print t<» tin- interesting 
phenomenon belongs to Ferdinand Tanzer; 8 although the late Mr. 
Garretson always emphasized this verj same fact in hi- lectures. 1 

tal < '.-in.-. 1892, i 

\ ierteljahraschj ifl . 1905, p. \~~ . 
writer is indebted to the late 1 >i \I . V < !ryer for this information. 



SECONDARY PULPITIS 129 

The overfilled bloodvessels exert pressure upon their walls and 
wherever they meet with resistance compression results, which 
manifests itself as pain. From an anatomic viewpoint, it is readily 
understood why this manifestation of pain is so much more pro- 
nounced in the dental pulp than in other soft tissues. As a con- 
sequence, any cause which may produce a general increased blood- 
pressure will leave its imprint upon this delicate organ. If the 
respective dental pulp is pathologically altered by an overgrowth 
or some other developmental defect of its surrounding hard wall 
of dentin, or if it has undergone degenerative changes, the pain 
arising from a plethoric circulation, i. e., a congestive hyperemia, 
is naturally more pronouncedly manifested in this particular dis- 
eased pulp than in a normal pulp. While any dental pulp by 
virtue of an existing pathologic lesion may be selected as the point 
of minor resistance, usually the pulps of the upper second incisors 
and those of all the lower incisors are more often the victims, as 
they may be classified as "weak" teeth. Clinical observations 
substantiate this conception. The resultant hyperemia manifests 
itself primarily as a dull, continuous pain which is much accelerated 
by sudden temperature changes. Aside from numerous general 
diseases which concomitantly produce high blood-pressure, there 
are specifically two physiologic factors, i. e., pregnancy and men- 
struation, which are prone to manifest themselves secondarily as 
pulpitis and, as a consequence, may induce the patient to seek the 
services of the dental practitioner. 

Secondary pulpitis as an affliction of the pregnant woman is 
exceedingly common either as an aggravation of some ordinary 
complaint caused by the mechanical effects of the uterine enlarge- 
ment or it may result from a reflex neurosis due to the extraordi- 
nary stimulus acting on the genital tract, or from that interesting 
and little understood interference with general metabolism, i. e., 
toxemia of pregnancy. 

Disturbances of menstruation are most frequently met with in 
girls and young women. Practically every civilized woman suffers 
more or less discomfort and malaise at this period, the most com- 
mon manifestations are pain and weight in the back and loins, 
abdominal cramps, headache, general lassitude, etc., occurring espe- 
cially the days before and during the menstruation. Mild types 
of gingivitis occurring during menstruation and pregnancy are 
exceedingly common. The increased blood-pressure very fre- 
quently sets up a painful secondary pulpitis and hence the appeal 
to the dental practitioner. 

Regarding the diagnosis of these cases, it may be stated that a 
carefully worded inquiry will usually reveal the underlying cause. 
Overscrupulous and sensitive patients require tactful handling. 
If the true cause is ascertained an assurance may be given that 



130 DISE [SES OF THE DE \ TAL PI LP 

with the termination of the physiologic disturbance the painful 
tooth will return to its norma] state of health without further 
treatment. In rare instances a pulp may die from the effects of 
increased intradental blood-pressure. 

Chlorosis, a pronounced type of anemia, is principally met with 
in young girls about the age of puberty and it manifests itself as a 
marked decrease of the hemoglobin content of the Mood. It is 
chief!} associated with disorders of menstruation. A.S a not infre- 
quent complication, a dull, continuous toothache in otherwise 
apparently sound teeth is observed. The underlying cause of this 
type of secondary pulpitis is usually recognized at once by the 
color of the patient. The change of the complexion is marked. 

viz., blonds become pallid and Waxy and brunettes muddy and 

grayish with bluish-black rings under the eyes. Chlorotic patients 

often manifest an increased tendency to dental caries. At presenl 
it is assumed that chlorosis causes a disturbance of internal secre- 
tions and the resultant change interferes with the ealeium metab- 
olism and thereby creates a predisposition to dental caries. Suit- 
able treatment consisting of plenty of food, fresh air, rest and iron 
will assist the patient in her return to normal health and thereby 
incidentally the secondary pulpitis is eradicated. 

Prognosis.— The prognosis of a pulp afflicted with secondary pul- 
pitis depends upon its original cause. If the secondary disturb- 
ance is brought about by a local infection of the investing tissues 

of the tooth, the coin omitant routine treatment of the initial cause 

and the existing pulpitis will restore respectively the pulp or the 
pulpless tooth to its former usefulness. In case the secondary pul- 
pitis is tin 1 sequence of a hematogenous infection, the prognosis for 
the ultimate recovery of the pulp is usually favorable. Leukemia 
and locomotor ataxia are unfavorable predisposing causes; these 
disease^ usually are fatal. 

Treatment. The treatment of a pulp afflicted with secondary 
pulpitis depends primarily upon the recognition of it s predisposing 
cause. If the existing pulpitis is the sequence of a local infection, a 
correct diagnosis of the respective condition of the diseased pulp 
will clearb indicate the mode of its treatment as outlined in the 
previous sections. It is understood that the primary cause, of 
necessity . must also be eradicated. If the secondary pulpitis mani- 
fests it-elf as an obstructive hyperemia, or even a mild type of 
acute pulpitis a- a sequence of a hematogenous infection caused 

by a general disease, guch as an acute catarrh of the antrum, inllu- 

enza, malaria, etc., or an exant hematoiis disease, /. i • .. measles, 
scarlet fever, etc, the successful termination of the causative disease 
usually restores the affected pulp to its former usefulness. The 
restoration of the afflicted pulp to it- normal activity under these 
conditions furnishes a splendid example of the ancient medical 



SECONDARY PULPITIS 131 

aphorism: Coesante causa, coesat morbus, i. e., Let the cause be 
removed and the disease ceases. If the operator has satisfied him- 
self that his patient suffers from a secondary pulpitis with no per- 
ceptible manifestations of local lesions and with no indications for 
specific dental treatment, he should always direct him to consult a 
general practitioner or a specialist, as the case may be, accompanied 
by such information as to guide him in regard to the apparent nature 
of the underlying ailment. 

The treatment of a type of secondary pulpitis which, as we have 
pointed out above, should be classified as a dental borderline disease, 
i. e., the simultaneous appearance of an acute catarrh of the maxil- 
lary sinus and an obstructive hyperemia of the pulps of the upper 
teeth of the afflicted side, requires detailed discussion. A patient 
suffering with this most annoying acute disturbance, which mani- 
fests itself as a severe continuous, dull, painful sensation of the 
affected side of the face and principally of the teeth within this 
region, usually consults his dentist and insists— and rightly so— 
that the pain is primarily located about his teeth. If the dentist 
has correctly diagnosed the condition the following symptomatic 
treatment will give excellent results. The patient is ordered to 
bed, light nutritious diet is prescribed and he is advised to take 10 
grains (0.65 gm.) of acetyl-salicylic acid (aspirin) every two hours 
with a cup of hot tea or a glass of water. Before going to sleep a 
hot lemonade is advised to promote free perspiration. Twice dur- 
ing the day (mornings and evenings) the afflicted side of the face 
should be placed upon the hot-water bag for a half hour. The 
nose and the mouth should be rinsed at frequent intervals with a 
warm physiologic saline solution. The patient should be cautioned 
against exposure to draughts as acetyl-salicylic acid seemingly pre- 
disposes to aerobic infection. Usually within a few days all 
symptoms have disappeared and complete recovery is assured. 

Occasionally a somewhat similar effect of an exposure to chilly 
dam]) air manifests itself in the lower jaw. A painful obstructive 
hyperemia of the pulps of the lower teeth of the affected side is the 
direct sequence. Principally, however, it is the temporo-maxillary 
joint which has to bear the brunt of the burden and it responds 
with a painful, acute inflammation of its synovial membrane. 
On opening of the mouth a "cracking" sound or a distinct momen- 
tary locking is observed, which is the result of the swollen intra- 
articular fibrocartilage being caught by the moving condyle. 
Pressure with the finger in front of the tragus of the ear and with 
the mouth wide open will cause a most painful sensation within 
that region which verifies the diagnosis. The condition may be 
referred to as an acute mandibular arthritic inflammation or as an 
arthro-rheumatic affection of the temporo-maxillary joint, i. e., 
rheumarthritis. 



L32 DISEASES OF THE DENTAL PI LP 

The treatment of this dental borderline disturbance, i. < .. second- 
ary pulpitis combined with Inflammation of the mandibular joint, 
is precisely the same as thai suggested above with one important 
adjunct, i. e,, temporary rest of the joint. The simplest method 
to obtain this required resl consists in applying a head-end-chin 
bandage padded thickly with cotton about the affected region to 
be worn during the night and if possible the greater part of the day. 
Salicylic acid in the form of an ointment, either a> the Compound 
Menthol Ointment, \.1\, or in the form of the ready-made Baume 
Analgesique Bengue, should he thoroughly rubbed into the -kin 
about the affected region on retiring. In addition, 10 grains 0. 65 
gm.) of atophan, combined with 10 grains (0.65 gm.) of sodium 
bicarbonate and suspended in a large glass of cool water, should 
l>e taken twice a day between meals. 



CHAPTER XII. 
CHRONIC ULCERATIVE PULPITIS. 

Synonyms. — Chronic ulcerative or parenchymatous inflamma- 
tion of the dental pulp, pulpitis chronica ulcerosa sen parenclnjmatosa. 

Definition.— A chronic ulcerative inflammation of the exposed 
pulp. 

Etiology.— The causes of chronic ulcerative pulpitis are practically 
always to be sought for in a mixed streptococcus invasion arising 
from the carious process through a more or less extensive break 
in the pulpal wall. 

Varieties.— Only one variety is known. 

Clinical Pathology.— The clinical picture of this disease is some- 
what hazy; only mild and frequently no subjective manifestations 
are observed. The affected tooth usually has a deep cavity or a 
badly leaking filling extending into the pulp chamber which allow 
free drainage of the products of suppuration. Occasionally a 
patient complains of a disagreeable sensation in the tooth, although 
real pain is rarely felt except when pressure from food debris crowded 
into the cavity produces a paroxysm which may last for some 
minutes, or until the pressure is relieved. No swelling of the 
surrounding tissues is observed. 

Pathologically, the exposed pulp presents a moist grayish-white 
necrobiotic surface, i. e., a suppurating ulcer. Below the debris a 
wall of dense granulation tissue is felt with a slowly advancing 
explorer which separates the necrotic tissue from the underlying 
chronically inflamed pulp. In the struggle for existence against 
the constant irritation brought about simultaneously by the infec- 
tion and the pressure from decomposing food crowded into the 
open pulp chamber, the pulp responds gallantly with all its forces 
of defense which results in the above referred to line of demarca- 
tion and leads to the deposition of adventitious dentin and pulp 
nodules within its own tissue. These nodules grow concentrically 
and may assume a size so large as to completely fill the pulp cham- 
ber or the root canal. The further disintegration of the remaining 
pulp is a very slow process. Depending upon the original vitality 
of the pulp, it may require many months for its completion. 

Subjective Symptoms.— The patient complains of very little 
discomfort; when food is crowded into the cavity, pain from pressure 
results which is relieved by its removal. Only in very advanced 
cases are secondary manifestations observed. 



i.;i 



DISEASES OF THE DE1\ TAL PULP 



Diagnosis. Chronic ulcerative pulpitis maj be accidentally dis- 
covered by an Inspection of the teeth. On excavating the cavity 
b break in the pulpal wall is revealed; the pulp chamber is filled 
with aecrobiotic tissue, and on inserting an explorer into the inflamed 
portion of the pulp severe pain is manifested. The application of 
cold produces pain, indicating inflammation; percussion is i 
tive. The roentgenogram may -how pulp nodules. The response 
to the electric current is usually the same as that observed in suppu- 
rative pulpitis, namely, a greater amount of current is necessary 
than normally. Chronic ulcerative pulpitis is a comparatively 
rare disease which at time-, offers great difficulties in its recognition; 
usually it i-> only observed in the neglected teeth of adults. 




Ii'.. li'.i. Chronic ulcerative pulpitis. 

Differential Diagnosis. An open pulp chamber and comparative 
freedom from pain are the principal pathognomonic signs of chronic 
ulcerative pulpitis and differentiate this disease from other types. 

Prognosis. A chronically inflamed pulp with an ulcerating 
surface does not offer favorable chances for its preservation; the 
removal of the diseased pulp and subsequent treatment of the r<»<»t 

canal restores the tooth to normal function. 

Treatment. ( Tronic ulcerative pulpitis calls for the same routine 
procedures as previously described under "Acute Suppurative 
Pulpitis." 



CHAPTER XIII. 
CHRONIC HYPERPLASTIC PULPITIS. 

Synonyms.— Chronic hypertrophy of the dental pulp, pulp poly- 
pus, productive inflammation of the dental pulp, pulpitis chronica 
hypertrophica, seu granulomatosa, seu plastica. 

Definition.— Chronic hyperplastic pulpitis is a chronic productive 
inflammation of the exposed pulp characterized by a slowly growing 
granulation tissue upon its surface, filling more or less the carious 
cavity and sometimes protruding therefrom. Correctly speaking, 
a polypus should be designated as a pedunculated swelling or out- 
growth of a mucous membrane and hence the term pulp polypus is 
misapplied. 

Etiology.— It is caused by a chronic irritation of a young growing 
pulp due to the rough edges of the broken walls of the pulp chamber. 
A large opening into the chamber seems to be imperative. The 
fungoid growth may be looked upon as an endeavor instituted by 
the irritated pulp to protect itself. 

Varieties.— One variety only is observed; it may occur as a simple 
small overgrowth of the irritated pulp tissue, or as a vascular mass 
filling the entire carious cavity or even protruding therefrom. On 
rare occasions the granulation tissue may relatively assume an 
enormous size. 

Clinical Pathology. —The clinical picture of a chronic hyper- 
plastic pulpitis, commonly referred to as pulp polypus, is very 
typical. Within the cavity of the tooth a deep red mass of granu- 
lation tissue, ranging in size from that of a pinhead to a large pea 
and often protruding from the cavity may be seen. In fractured 
teeth a fungoid growth of the exposed pulp is occasionally observed. 
On touching the growth with the finger, pulsation may be felt; 
the patient does not complain of real pain. A slight wound in its 
surface causes a profuse hemorrhage. Pathologically, this new 
growth is a typical hypertrophy and consists of slowly growing 
granulation tissue endowed with a rich blood supply and an absence 
of nerve fibers. Correctly speaking, it is not a neoplasm (tumor). 
The odontoblasts disappear, hence the polypus does not respond 
painfully on being touched except upon increasing pressure, which 
calls forth a reaction from the pulp proper. With the increase 
in its size the polypus may protrude from the cavity of the tooth, 
and by its close contact with the gum tissue may become covered 



136 



DISEASES OF THE DEh TAL PULP 



with epithelium, as a consequence of mechanical irritation. It 
should be remembered thai the normal pulp does not contain this 
latter tissue, hence the observed epithelial covering is the result of 
a process of autotransplantation from the surrounding mucous 
membrane. 

Chronic hyperplastic pulpitis is a comparatively rare disease; it 
is usually restricted to molar teeth with large crown cavities, and 
is most frequently observed in the neglected oral cavities of children. 
It may be looked upon as an expression of a powerful defensive 
process brought about by chronic irritation of a young growing 
pulp present in the mouth of an otherwise healthy individual. 




Fig. 70.- Chronic hyperplastic pulpitis. Pulp polypus. 

Subjective Symptoms. Subjective symptoms manifest themselves 
as an unpleasant sensation, which, however, i> not expressed as 
real pain. Upon pressure from food crowded into the cavity or 
from other sources of irritation a painful response is obtained from 
the chronically inflamed pulp. Secondary symptoms are rarely 
observed. 

Diagnosis. Chronic hyperplastic pulpitis Is readily diagnosed 
by physical inspection; its principal diagnostic features are com- 
parative freedom from pain on slight pressure, very free bleeding 
when wounded and the presence of one or more peduncles which 
attach the granulation tissue to one or more horn- of the pulp. 
An explorer inserted into the pulp proper call- forth ;i very painful 
reaction, as the pulp is always found in a chronic state of mild 
infl a mm ation. The electric current verifies this latter diagnosis. 
Pericementitis a- a sequel is rarefy observed. 

The differential diagnosis is primarily concerned with the differ- 



CHRONIC HYPERPLASTIC PULPITIS 137 

entiation between the pulp polypus and the gum tissue which may 
have grown into the cavity. The rough edges of the cavity may 
irritate the gum tissues and ingrowing hypertrophic gum is a very 
common occurrence. The latter also bleeds very freely, but is 
slightly more painful on being injured. Lifting up the questionable 
tissue usually reveals its identity. In cases of doubt packing the 
cavity with temporary stopping for twenty-four hours will clarify 
the diagnosis. 

Prognosis.— As the pulp is always found in a more or less pro- 
nounced state of chronic inflammation, its destruction and removal 
is indicated. The prognosis of saving the pulpless tooth usually 
is good. 

Treatment.— The treatment of chronic hyperplastic pulpitis con- 
rists in the preliminary surgical removal of the granulation tissue 
and destruction of the remaining pulp. To facilitate the painless 
amputation of the polypus a drop of liquid phenol is allowed to 
flow upon it and very shortly the cauterized head, which now 
appears as a milk-white bead, may be cut off with a sharp spoon 
curette or a hatchet-shaped excavator, or with a small curved lancet. 
Profuse bleeding results. The further treatment, i. e., the removal 
of the pulp, etc., is carried out as discussed under "Devitalization 
of the Dental pulp." 



CHAPTER XIV. 
DEGENERATION OF THE DENTAL PULP. 

Synonyms Chronic parenchymatous pulpitis; atrophy of the 
pulp, pulpitis chronica parenchymaiosa, atrophia pvlpce. 

Definition. Chronic parenchymatous degeneratiou of the pulp. 

Etiology. Atrophy of the pulp is primarily caused by natural 
senile, retrogressive, metamorphotic changes within the pulp tissue 
Independently of inflammatory processes. Pathologists recognize 
amyloid, atrophic, Patty, fibroid and calcareous varieties. 

Clinical Pathology. In the absence of any recognizable symptoms 
of the unexposed pulp there is no clinical picture to be observed. 




Fig. 71. — Degeneration of the dental pulp 



Pathologically, degeneration of the pulp is most frequently and. 
incidentally, rather commonly met with in the teeth of the aged; 
it i^ an eminently chronic process. It maj be restricted to the 
periphery of the pulp: usually, however, it involves the whole 
organ. The degenerated pulp presents the typical picture of a 
retrogressive metamorphosis, t. e., dilated bloodvessels, degen- 
erated nerve fibers, reticular atrophy or adenoid degeneration of 
its connective tissue and reduction of the size of the odontoblasts. 
The various types of degeneration present definite pathol 
phases, which are onl\ recognizable microscopically. As the elm- 



DEGEXERATIOX OF THE DENTAL PULP 



139 



ical practitioner cannot diagnose atrophy of the pulp in situ, an 
ex cathedra discussion of its pathology would prove of little service 
to him. For further information on this subject the reader is 
referred to the works of Hopewell-Smith, Black, Wedl, Walkhoff, 
Roemer, Bennet, etc. 

Subjective symptoms are absent. 

Diagnosis.— An unexposed atrophic pulp cannot be diagnosed. 
More or less complete absence of sensation with negative findings 
in regard to the color of the tooth, to conductivity of temperature, 
transillumination, percussion and the roentgenogram furnish suffi- 
cient proof to substantiate the above dogmatic statement. The 




Fig. 72. — Degeneration of the dental pulp. Magnified section of Fig. 71. 



slightly lowered resistance of a pulp undergoing atrophic changes 
to the faradic current and other diagnostic aids are too meager to 
be of assistance in the recognition of degenerative changes occurring 
within this organ. Naturally, a completely degenerated pulp is a 
"dead" pulp, and, as a consequence, no response is obtained by the 
electric current. 

Prognosis.— The extirpation of the atrophic pulp and the subse- 
quent routine treatment and filling of the root canal restores the 
affected tooth to its former usefulness. 

Treatment.— On opening the pulp chamber of a tooth by intent 
or accidentally containing an atrophic pulp, the operator at once is 



1 in DISE iSES OF THE DENTAL PI LP 

forcibly Impressed with three jointly existing conditions which are 
contrary to his expectations, i. e,, a partial or more often a total 
absence of all sensation, no hemorrhage and an absolute freedom 
from putrescent odor. The extirpated pulp presents itself as a 
shriveled wax-like or fibrous thread of a yellowish transparent 
color or having a reddish-brown tint. On crushing the extirpated 
tissue, pulp nodules may be felt. The clinical diagnosis of defen- 
eration of the dental pulp is assured by these pathognomonic find- 
ings. Most frequently the root canals will be found partially or 
totally obliterated by calcareous deposits. The root canals, emptied 
of its contents, in the absence of a bacteriologic examination, should 
always be looked upon as infected and treated accordingly 
outlined under "Necrosis and Gangrene." 



CHAPTER XV. 
DEVITALIZATION OF THE DENTAL PULP. 

The successful application of therapeutic measures to a diseased 
pulp for the purpose of bringing about its resolution unfortunately 
is restricted to very limited bounds. The only absolute safe 
prognosis of an inflamed pulp consists in its destruction. Clinical 
experience bears out the fact that the latter procedure, if carried 
out under aseptic precautions, is eminently successful and the 
removal of the pulp does not materially jeopardize the future useful- 
ness of the involved tooth. Aside from numerous pathologic 
interferences with the normal equilibrium of the dental pulp, the 
practitioner is frequently called upon to destroy this organ for 
many other reasons. 

The indications for the devitalization and removal of the dental 
pulp may be summarized as follows: 

1. All cases which, in accordance with the judgment of the 
operator, offer only questionable chance for resolution, i. c, expo- 
sure of the pulp, hyperemia and the early states of acute pulpitis. 

2. All the other disturbances of the pulp as discussed under their 
respective headings in the previous chapters. 

3. All cases of extensive carious destruction of the crown of a 
tooth involving its pulp which call for an artificial substitute. 

4. Certain cases of malformation, malposition or other esthetic 
defects which call for an artificial substitute of the distorted crown. 

5. Certain cases in which a sound tooth is to be utilized as a 
post for anchoring an artificial substitute. 

The various methods employed for the devitalization of the 
dental pulp may be carried out according to the following procedures. 

1. Destroying the living pulp by purely mechanical means, i. e., 
"knocking out" of the pulp without an anesthetic. 

2. Destroying the pulp under a general or a local anesthetic. 

3. Destroying the pulp by the actual cautery or a potential 
caustic. 

Destruction of the Pulp by Mechanical Means Without an Anesthetic. 
—In bygone days the removal of a pulp by purely mechanical 
means, i. e., the extirpation of the exposed pulp by inserting a 
broach or by "knocking out," as this barbaric process is known, 
was in common vogue. Fortunately, it is rarely practised at 
present. The "knocking out" process consisted in driving a suit- 



1 !_' DISEASES OF THE DENTAL PULP 

able shaped wooden stick into the pulp chamber by the quick blow 
of a mallet. In defense of the advocates of this method, it musl 
be stated that the pain experienced from this procedure when 
dextrously performed Is comparatively little, provided that the 
pulp Is in ;i perfect state of health, which, however, Is rarely the 
ease and which, incidentally, cannot always be ascertained with 
any degree of absolute satisfaction. However, with the present 
methods of inducing local anesthesia there is no valid reason for 
the continuation of 3ucfa heroic procedures. 

Destruction of the Pulp Under a General or a Local Anesthetic. 
As a general anesthetic produces insensibility of the pulp precisely 
in the same manner as in any other organ of the body, no further 
discussion is necessary at this moment. The administration of 
nitrous oxid or some other general anesthetic agent is occasionally 
employed for such purposes. The so-called "dental analgesia" is 
not to be advised for the "painless" removal of the pulp. The 
administration of a local anesthetic for this specific purpose is at 
present so eminently successfully and widely practised, that its 
technic, of necessity, must be discussed in detail. 

Injection into the Pulp (Pressure Anesthesia). By pressure anes- 
thesia, pressure cataphoresis, pulp anesthesia or contact anesthesia 
as this process is variously termed, we understand the introduction 
of an anesthetizing agent in solution by mechanical means through 
the dentin or directly into the exposed pulp for the purpose of 
rendering this latter organ insensible to pain. Simple hand press- 
ure with the finger or with a suitably shaped instrument, with 
the hypodermic syringe or with the so-called high-pressure syringe 
is recommended for such purposes. 

Before describing the modus operandi of the various method-. 
the histologic structure of the dentin should be briefly recalled. 
Dentin is made up of about ~- per cent inorganic salts, about in 
percent water and an organic matrix constituting the remainder. 
The dentin is traversed by a very large number of tubules, radiating 
From the pulp cavity in a more or less wave-like manner toward the 
periphery \\ here they branch off, forming a deltoid network. These 
tubules arc filled with the processes of the odontoblasts, known at 
present as Tonic-' fibers, and they are concerned with the metabolic 
changes occurring in the dentin. The dentinal fibrils are proto- 
plasmic in their nature and normally do not carry physiologic 

Sensation in the Sense as we understand this term. When the 

fibers have become highly irritated a mere touch upon the dentin 
ma\ at once call forth a parox} sm of pain. 

1 . Devitalization of the Pulp when Exposed or Covered with a 
Layer of Decalcified Dentin, [solate the tooth with the rubber dam. 

and clean it with an antiseptic solution. Kxcavate the cavity as 

much as possible, and if the pulp is not fullj exposed wipe out the 
ca\ it\ w ith chloroform to remo> e fatty deposits from the cartilagin- 



DEVITALIZATION OF THE DEXTAL PULP 143 

ous layer of dentin, and dehydrate with absolute alcohol and warm 
air. Saturate a small pledget of cotton with a warm concentrated 
novocain (procain) solution in sterile water, place it into the prepared 
cavity or over the exposure and cover it with a large pledget of 
cotton, and then, with a piece of slightly warmed unvulcanized 
rubber so as to render it plastic and which should about completely 
fill the cavity, and with a broad-faced amalgam plugger or some 
other suitably shaped instrument, apply slowly increasing con- 
tinuous pressure from one to three minutes. The pulp may now 
be fully exposed and tested. If it is still sensitive repeat the pro- 
cess. LoefBer states: "This pressure may be applied by taking 
a short piece of orange wood, fit it into the cavity as prepared, and 
direct the patient to bite down upon this with increasing force. 
In this way we can obtain a well-directed regulated force of pressure 
and with less discomfort to the patient and the operator." 

Miller described his method as follows: "After excavating the 
cavity as far as convenient and smoothing the borders of it, take 
an impression in modelling compound, endeavoring to get the 
margins of the cavity fairly well brought out; put a few threads 
of cotton into the cavity and saturate them thoroughly with a 5 
to 10 per cent solution of novocain, cover this with a small bit of 
rubber dam, and then press the compound impression upon it. 
We obtain thereby a perfect closure of the margin, so that the liquid 
cannot escape, and one can then exert pressure with the thumb 
sufficient to press the solution into the dentin." Instead of the 
novocain solution, a so-called novocain "pluglet" may be used. 
A pluglet is introduced into the cavity, covered with a wisp of 
cotton dipped in sterile water and the further procedure is precisely 
the same as described above. 

2. Devitalization of the Pulp when Covered with a Thick Layer of 
Healthy Dentin.— With a very small bi-bevelled drill bore through 
the enamel or directly into the exposed dentin at a convenient 
place, guiding the drill in the direction of the pulp chamber. Blow- 
out the chips, dehydrate with alcohol and warm air and apply the 
hypodermic or high-pressure syringe, provided with a special 
needle, making as nearly as possible a water-tight joint. Apply 
slow, continuous pressure for two or three minutes. With a bur 
the pulp should now be exposed, and, if still found sensitive, the 
process is to be repeated. As an anesthetic solution for this pur- 
pose, a 5 per cent solution of novocain in sterile water is recom- 
mended. Or a wisp of cotton saturated with the same solution or 
a moistened novocain pluglet is placed in the hole, covered with 
dry cotton and a piece of very plastic unvulcanized rubber and 
pressure is made with an instrument that will just about fit into 
the opening. 

Within recent years a number of complicated syringes, variously 
known as high-pressure syringes or obtunders, have been advocated, 



HI 



DISE iSES OF THE DBA I'M. PULP 



based upon the principle of forcing anesthetic solutions through 
sound tooth substance with intense pressure. This conception of 
pressure anesthesia is erroneous. Close contact of the anesthetic 
fluid with the dentinal fibers, plus the necessary time for conveying 
the absorbed anesthetic via the Tomes' fibers to the oerve endings, 
explains the phenomenon very plausibly. A strong metal syringe, 
provided with a specially prepared needle to make as near as 
possible a water-tight joint, is all that is required. Those who 
prefer a special high-pressure syringe for such purposes ma) pur- 
chase any one of the many devices that will suit their fancy . The 
Weaver obtunder or the Jewett-Willcox syringe i> much landed 
for such purposes. Any one of the various method- for anesthetiz- 
ing a tooth as outlined under "Local Anesthesia as Applied to 
Operative Dentistry" may also he used for anesthetizing the pulp. 



CH53!S10nS0HE 




■Weaver high-pressure <>l»: iiikIiiilt syringe. 



In teeth not fully calcified and in so-called "soft" teeth, pressure 

anesthesia produces mosl satisfactory results, while the process is 

applied with difficulty in teeth of elderly persons, teeth of inveterate 

tobacco chewers, worn, abraded and eroded teeth with extensive 

ndary calcific deposits, teeth whose pulp canals are obstructed 

by pulp nodules, teeth With metallic oxids in their tubules, teeth 

with leak\ old fillings, badly calcified teeth, mainly all from one 

and the same cause, namely, clogged tubules. In most cases no 
amount of persistent pressure will prove successful. 

According to Hertwig the protoplasm of the eell primarily trans- 
fers irritation and, secondarily, transmits absorbed materials, and 
therefore the anesthetic solution has to pass through the entire 
length of the dentinal fibrils before the nerve endings of the pulp 
proper are reached. Consequently a certain period of time is 
required before the physiologic effect of the anesthetic is mani- 
fested, and this period of latency i> dependent on the thickness of 



DEVITALIZATION OF THE DEXTAL PULP 145 

the intermediate layer of dentin. The successful anesthetization 
of the pulp depends largely on this most important factor of allow- 
ing sufficient time for the proper migration of the drug. 

Other soluble local anesthetics, such as nervocidin, erythrophlein 
hydrochlorid, quinin and urea hydrochlorid, etc., have been advised 
at various times as reliable pulp anesthetics. Owing to numerous 
drawbacks, these drugs have never obtained popularity. Refrig- 
erant local anesthetics have also been advised for the extirpation of 
the pulp. The application of this group of anesthetics for such 
purposes is usually accompanied by many disadvantages which 
materially limit their usefulness. 

Destruction of the Pulp by the Actual Cautery or a Potential Caustic 
— Devitalization of the pulp by the actual cautery or a potential 
caustic has been in the past more freely used than any other method. 
Before entering into a discussion of the various procedures employed 
in their application, it is probably not amiss to rehearse their 
pharmacologic action. 

Caustics, sometimes called escharotics, are substances which 
destroy living tissue by virtue of their coarse chemical or physical 
action, affecting organized as well as unorganized albumin. The 
older medical lexicographers restricted the term escharotic to sub- 
stances which produce a dry, more or less insoluble, protective 
slough. They further differentiated between the actual cautery, 
i. c, tire red-hot iron, and the potential cautery, i. e., an agent, 
like silver nitrate, which forms an eschar without the agency of 
actual fire. 

True caustic action manifests itself essentially in two definite 
ways: It produces coarse chemical or physical changes in the 
tissue which are macroscopically recognizable or it causes more or 
less direct death of those affected tissues. Pure chemical drug 
action on living cell structures which endangers, or even kills, the 
cell without visible changes is referred to as protoplasm poisoning, 
while a drug which produces severe visible tissue changes, but 
without cell destruction, is spoken of as an irritant. A concrete 
example of differentiation between a caustic and a protoplasm 
poison is readily furnished by a comparison of the action of the 
following two drugs: If a dram of pure sulphuric acid is swallowed 
it will, by cauterization, destroy the tissues with which it comes 
in contact and thereby finally kills the individual. If the same 
amount of acid is dissolved in a quart of water and drunk, it will 
practically do not visible harm as it is now so very diluted as to be 
inactive. If, on the other hand, a protoplasm poison, as for instance, 
3 grains of arsenic, are taken as a dose, whether it is in the form of a 
powder or dissolved in a quart of water, it will always kill a man, 
no matter how well diluted. 

In the early days of the practice of conservative dentistry, as 
Fauchard, Bourdet, Hunter, Koecker and others inform us, the 
10 



146 DISEASES OF THE DENTAL PULP 

actual cautery was freely employed for destroying the "nerve" of 
a tooth. The method utilized for this purpose was practically the 
same as thai employed by Koecker for "burning the nerve" p. 
104). At present the electric cautery is very rarely employed, 
while the potential caustics, such as nitric acid, silver citrate, 
"spiril of salt" hydrochloric acid), which were also recommended 
in bygone days, have only a limited usefulness. In L833 Wood 
advocated the use of crude arsenic (flystone, ratsbane or native 
cobalt bloom) 1 for the destruction of the dental pulp. Three j ears 

later, in L836, Shearjashnl) Spooner,- of New York, published an 

excellent little hook entitled Gwde to Smturf Teeth, or a Popular 
Hse on the Teeth, in which he recommended to the dental pro- 
fession for the first time the use of arsenic trioxid for the ab 
purpose. It is stated that Chaplin Harris, of Baltimore, used 
arsenic in 1835 without having knowledge of Spooner's discovery. 
The original description of the introduction of arsenic trioxid 
for the destruction of the dental pulp by Spooner is, from a historical 
point of view, most interesting and is here appended in outline. 1 

> Crude cobalt, better known as flystone (Scherben Kobalt) is an impure ooball 
arsenate containing variable quantities of arsenic. The pure metal coball is, pharma- 
cologically, an inert Bubstance; in its crude form its action depends upon the pn 

of arsenic. 

■ Spoon.r, Shearjashub: Guide to Sound Teeth, I : 

•TrBATMHNT OF ill I : TbETB WHBN ( 'arieS Has PbOOBESBBO TO mi. N. 

When decay has extended to the nerve and causes the tooth to ache extraction is 
the usual remedy resorted to by all who have sufficient resolution to induce them to 

undergo the operation. The teeth are BO liable to caries in this country, and 
decay at so early an age and so rapidly, that it is a matter of very great importance 

to all, especially to those who have l>een so unfortunate as to lose many teeth, whether 

some means cannot he devised for their preservation. This desideratum ha- 

happily discovered, and its succe— has been thoroughly tested, in a practise of many 
years. The uervee of the teeth may he certainly and effectually destroyed, with 

little or no pain to the patient and without the Least danger, by means of a little 

arsenioufl acid (arsenic, ratsbane) applied to the nerve. We claim for our brother, 

Dr. .1. U. Spooner. of Montreal, the Credit of this valuable discovery and for OUR 

lit for thus frankly Laying it before the dental proles-ion and 

the public. We have proved that the vitality of the fangs of the teeth, which is 
lary to prevent them from acting as foreign bodies in tl 

,1 ii|""' the internal membrane or nerve. This fact is of greater importance 
than on.- would Suppose at a lir<t view, for thousand- of aching teeth which are daily 

i,,.;,, , may be effectually preserved by taking advantage of it. This is a 

much moment to those \\h<> have been unfortunate a- to Lose many I 
mplete and satisfactory i- the operation of arsenic in destroying tin- Living fiber, 
that instead of extracting teeth whenever the cerve is badly exposed, we deetroj it. 
phjg the tooth and thus preserve it. Teeth thus treated will often last a greal 

e highly serviceable, Arsenic will aot only positively destroy the 

a of the teeth, but it possesses the greal advantage that it d ithout 

, m . if it bt applied to an aching tooth it slightly augments the pain, 

but w hen applied to a aen e, not inflamed, it does not cause any pain worth minding . 

, ,,- p.. i applied to .-whin- teeth a mixture composed <>■ at -■ nic, :'. parte, and 

morphine, l part, the morphine being the most powi rful odontal 

Si \ iolenl toothache may be effectually cured without 

additional pain, a oircumstanoe well worth oonsidering. We cannot I 
tmenl to the public under the oiroun 



DEVITALIZATIOX OF THE DENTAL PULP 147 

The specific action of arsenic on the tooth pulp may be epito- 
mized as follows: If applied to an exposed normal pulp it is readily 
absorbed. Pronounced hyperemia and consequently increased pain 
are the early manifestations of the arsenic action. The vascular 
system is most readily affected by it and very pronounced dilation 
of the vessels, especially the capillaries, with more or less stasis of 
the circulation is the outstanding feature of its initial effect. "The 
walls of the capillaries are exceedingly delicate, being formed by a 
single layer of endothelium, which is a continuation of the endothelial 
lining of the arteries on the one side and the veins on the other" 
(Hopewell-Smith) . The endothelial coat of the capillaries is quickly 
corroded, causing multiple hemorrhages. Destruction of the blood 
plates, i. e., plasmolysis and plasmorhexis, immediately follows, 
resulting in granular detritus. Thrombosis and stasis are the 
direct sequences. The connective-tissue fibers and the odonto- 
blasts are but little altered. The primary point of attack on the 
nerve centers is located in their endings, causing a destruction of 
the myelin and a more or less pronounced neuritis results; the 
latter is usually followed by complete cessation of all pain. The 
pronounced disturbances of nutrition finally result in anemic col- 
lapse and shrinkage of the entire pulp mass. 

On pathologically altered pulps aresenic acts very much in the 
same manner; its action is somewhat increased in the early forms 
of pulpitis, but usually slower in those cases in which severe inflam- 
mation and suppuration is predominating. An existing neuritis is 
always markedly increased. Depending on the vascularity and the 
size of the pulp, and the quantity used, from a few hours to two to 
five days are usually required for its progressive destruction. 
Strangulation of the pulp about its apical end, resulting from the 
intense hyperemia, brought about by the action of arsenic, is not 

No selfish views evidently actuate us in making these declarations. They are not 
the puffs of pretenders. Arsenic is the only substance with which we are acquainted, 
that will effectually destroy the nerve of a tooth. Nitric acid and nitrate silver 
have been much employed for this purpose. They were favorite toothache remedies 
with Hunter and Abernethy, but they do not generally do this effectually; they only 
destroy the surface of the nerve; indeed but the small portion of it is exposed; besides 
they destroy the tooth. A hot wire is the remains of barbarism, cruel as death and 
does not become the present enlightened day. A drill, as well as the hot iron, is very 
painful, and is enough to strike horror to the soul of a patient. The arsenic affects 
the object like a charm, and under proper management never fails of complete 
success. Many persons, of course, would be apprehensive of danger from its use; 
o 1 ,, grain is quite enough to destroy the nerve of any tooth. But let no ignorant 
person dabble with this remedy. As we recommend it so strongly, it is a duty 
incumbent on us to caution the public. There are many who would have no hesita- 
tion in filling a large hollow tooth with arsenic, on the strength of this recommenda- 
tion. There are some who do not know even what it is! We know of one instance, 
and but one, thank Heaven, in which the application of the remedy was attended 
with fatal consequences, and we merely mention it as a warning to presuming quacks. 
We have used this remedy in hundreds of instances, without ever experiencing any 
ill effect; nor can any danger ever attend its proper application. Whenever the 
nerve of a tooth can be preserved it should not by any means be destroyed. 



1 Is 



DISEASES OF THE DEh TAL Pi LP 



the direct cause of its death; in teeth with undeveloped or in those 
with partially absorbed roots, strangulation is very doubtful. 

Since the introduction of arsenic trioxid for the purpose of 
destroying the dental pulp many substitutes have been advocated, 
bu1 none have so far superseded it or taken its place. Aside from 
the application of local anesthetics by special methods, arsenic 
trioxid is -till the mosl universal agent employed for the above 
purpose. Usually it is applied in the form of a paste, sometimes 
as arsenical Bber or disks and as a dry powder. Innumerable 
Formulas for compounds of arsenic with other <\vu^ are suggested 
for such purposes. The principal objeel has always been to com- 




Fia. 74. A put 



i Moginier.) 



bine arsenic trioxid with an anesthetic. Manj of the published 
formulas represent empirical compounds, which arc put together 
in utter disregard of the pharmacologic action of the individual 
drugs. If the pulp is in a normal condition, very little or no pain 
is manifested bj the arsenical application; if the nerve cells are 
inflamed or are undergoing necrobiotic changes the increased irri- 
tation brought about bj the powerful oxidation and reduction as a 
result of the pharmacologic action of arsenic increases the already 
existing neuritis, and more or less severe pain results. Arsenic is 
\cr\ diffusible; it quickly destroys the nerve endings, and con- 
sequently there is little chance For the anesthetic which may be 



DEVITALIZATION OF THE DENTAL PULP 



149 



added to it to exercise its specific function. For this very reason 
the addition of a local anesthetic is of no benefit. 

For many years the original formula of Spooner, consisting of 
arsenic trioxid, morphin acetate and creosote, has been and is still 
used with apparent good success. Morphin applied locally has no 
anesthetic or narcotic effect on sensory nerve endings, and conse- 
quently it acts merely as a diluent of the arsenic trioxid. Cocain 
or its substitutes added with the expectation of mitigating the pain 
or the irritating effect of the arsenic trioxid is, to say the least, 
questionable. Scientific proof of this supposition has certainly 
never been brought forward. Nevertheless, there is less objection 
to their use than to most of the other narcotics. Additions of 
aconite, eserin, opium or its alkaloids, iodoform, etc., are useless, 
as they simply interfere with the ready absorption of arsenic. A 



AflE*jS%?]6 


f33S w "fl£^'«^»KffiSjMEl- ■;• '*" • . - f i 






& ; 'jtffc : ' fiL 


■Cv-- - v 


JPHH^% 


^fe^P 


&£, 


m 






>> ■ 

' .'■ 











Fig. 75. — Y) 



lizcd pulp. Magnified section of Fig. 



(Moginier.) 



more rational procedure consists in applying to an aching pulp a 
concentrated solution of a local anesthetic prior to the application 
of the arsenical paste. It is claimed by Lipschitz that the applica- 
tion of liquid phenol to the exposed pulp for at least ten minutes 
prior to the placing of the arsenical dressing will prevent pain 
arising from the action of the devitalizing compound. 

The addition of an antiseptic to the arsenical paste is illogical. 
Arsenic is a powerful antiseptic in itself, although it is well known 
that the cell walls of the lower organisms (bacteria) possesses a 
greater resistance to its action than those of the higher organized 
cells. Tanning agents are frequently added to the paste for the 
purpose of changing the pulp tissue to a leathery material, so as to 
facilitate its ready removal. Tannic acid or the various forms of 
formaldehyd are used for this purpose. It is better practice to 



150 DISEASES OF THE bi:\ 'I'M, PULP 

apply such agents after the arsenic dressings has been removed; 
the less we Interfere with the absorption of the arsenic, the better 
and quicker will be the results. 

As a vehicle for the paste, only such media as are more or less 
solvents of arsenic trioxid, or which allow it- read} absorption bj 
the pulp, art* justified. Glycerin, lanolin, vaselin, phenol, creosote, 
or the essentia] oils, and similar liquids, have been used for man) 
years as vehicles for the paste; their influence on the action of 
arsenic Is apparently of very little consequence; they certainly do 
not exercise their typical pharmacologic action in this connection. 
Strong coagulants should not be used as thej hinder the ready 
absorption of the poison by forming a seal). To give a distinct 
color to the paste, very small quantities of lamp black or carmin 
may be added. Some practitioners prefer to apply arsenic in the 
form of a paste mixed with eotton fibers, or in the form of paper 
disks saturated with a soft paste. Arsenical fiber i> prepared by 
mixing cross-cut cotton with the paste, and the disks are made by 
saturating very small square of hard white blotting paper with the 
thin paste, which are then dried and preserved. 

Trior to the application of arsenic, the cavity must he excavated. 
as arsenic will not act through disorganized dentin, and, if possible, 
the pulp should be exposed and thoroughly depleted, either by 
puncturing the organ or by applying vasoconstrictor drugs. Lav- 
age has been recommended for this purpose, i. e., washing the pulp 

with lukewarm water, changed slowly to cold water. Quicker 

results are, however, obtained by applying epmephrin chlorid 
solution under pressure. The cavity must be U-w from blood to 
prevent the formation of inactive arsenic hemoglobin. If the pulp 
is inflamed and painful it is absolutely necessary to apply suitable 
sedative remedies to relieve the conditions before the paste is 
applied; an inflamed pulp materially hinders the ready absorption 
of arsenic, and continuous severe pain is certain to follow. A 
solution of novocain or chloretone in oil of clove is serviceable for 
this purpose. These remedies, if sealed into the cavity, usually 
alleviates the condition in from twenty-four to forty-eight hour-. 
If pus is present it must be drained off. Pulp nodules occasionally 
obstruct the ready diffusion of the chemical. Removal of these 
calcareous deposits by means of a drill, after pressure anesthesia 

has been applied, i> indicated. (ocain should never be applied 

cataphorically under these conditions, as the electric current may 
drive the previously applied arsenic through the apical foramen 
into the -oft tissues. Occasionally one meets a patient w ho presents 
an unexplained idiosj ncrasj to the action of this chemical. 

The cavity for the reception of the arsenical application should 
be of ready access, and so prepared as to easily retain the temporary 

lilling. 'The arsenical compound is preferably placed in direct 



DEVITALIZATION OF THE DENTAL PULP 151 

contact with the freely exposed pulp by means of a blunt instru- 
ment, or on a depressed metallic disk or a piece of cardboard, or 
on cotton or spunk. Close contact insures quick action. Arsenic 
will act by osmosis, although slower, through any thickness of 
dentin. This very fact is the reason why its use as a remedy for 
hypersensitive dentin has been abandoned; death of the pulp is 
invariably the sequence of such procedures. Some operators prefer 
to cover the arsenical dressing with an intermediate film of plain or 
oiled paper, or a pledget of cotton. 

The final sealing of the cavity consists of a temporary filling of 
cement or of a gutta-percha preparation. Extreme care should 
be exercised in this simple, yet most important, operation. Cotton 
fibers mixed with sandarac or mastic varnish, to be used as a 
retaining medium, should be avoided; they readily become foul 
in the fluids of the mouth, or they may leak, and, besides, they 
swell, causing pain from pressure on the pulp. Kirk has advocated 
the use of surgeon's rubber plaster where but a portion of the tooth 
is left, carrying it around the tooth; it will adhere satisfactorily 
for several days or long enough to accomplish the object. The 
gutta-percha preparations are the best media for a temporary dres- 
sing seal; most experienced operators agree that a cavity correctly 
sealed with this material offers less possibilities for the seeping 
through of the drug than the various cements, etc. In applying 
the temporary stopping it is very essential to avoid pressure on the 
dressing. In proximal cavities, where overhanging tooth sub- 
stance prevents ready access, and therefore presents danger of 
misplacing the arsenical dressing, gutta-percha packed between the 
two teeth is of service. 

The quantity of arsenic necessary for the destruction of a pulp 
is very small. A careful estimation based on diverse weighings of 
quantities of arsenical paste, as employed by several practitioners 
in their routine work, has shown that the average application 
weighs about ■£§ grain (0.002 gm.). It is not only useless, but 
decidedly dangerous, to employ more. Other writers have esti- 
mated the amount as varying from yj-^ to t>V grain. 

In deciduous teeth, and in those of young persons where the 
roots have not fully formed, the arsenical paste should be left in 
the cavity only a few hours. Many practitioners are opposed to 
its use in the teeth of children. More than two teeth should not 
be subjected to the treatment at one sitting, to prevent a possible 
chance of an accidental swallowing of a large amount of the poison. 

The time required for the destruction of the pulp with arsenic 
depends on many circumstances. In the young, on account of the 
vascularity of the organ, from four to eight hours are usually 
sufficient. In people of mature age it is best to leave the appli- 
cation in situ from three to four days. This allows ample time for 



152 DISEASES OF THE DENTAL PULP 

the breaking down of the entire pulp and it- ramifications. Many 
pulps do not, however, require more than one <>r two days to suc- 
cumb to the effects of the poison. After the arsenic has been 
removed it [swell to seal an astringent into the cavit) for twenty- 
four hours, it will greatly facilitate the ready removal of the pulp 
in toto. Occasionally it Avill be found that in the removal of the 
pulp the apical half is still very sensitive to the touch. If it becomes 
necessary to again applj arsenic in the root canal a very small 
quantity of the paste carried on the end of a barbed broach which 
is quickly thrust into the pulp stump, should be employed. 

The following important facts should be remembered when 
an arsenical compound is used for the purpose of destroying the 
pulp: 

1. Only the smallest possible quantity which w\\\ kill the pulp 

should be used. 

2. Arsenic should never be applied on a severely aching pulp. 

3. On teeth with partially absorbed or with undeveloped roots 

the arsenical paste should remain only from four to six hours. 

1. If possible, the paste should be applied on a freely exposed 
and depleted pulp. 

5. A retaining seal must be applied without pressure and with 
the utmost care. 

Local toxic effects in the mouth are most frequently met with 
as the result of faulty application of the chemical for dental pur- 
poses. Leakage of the dressing seal is responsible in most cases, 
and contact of the mucous membrane with instruments accidentally 
carrying small particles of the paste, or the unnoticed squeezing 
out of arsenic resulting from pressure applied on placing the retain- 
ing stopping, are possible factors. The fact that arsenic trioxid 
is odorless and tasteless increases this danger, which usually is 
recognized only after the mischief is done. Numerous cases of 
severe forms of toxic periostitis, followed by necrosis <>f the alveolar 

process, and loss of one or more teeth, are on record. 

Lateral passage of arsenic or any other drug through the dentinal 
tubules and the cenientum into the pericementum doe- not occur. 

The homogeneous, structureless layer of cementum, by virtue of 
it- position, acts as an efficient barrier to the outward passage of 

drugs placed in the root canal. 

Arsenical intoxication of the gum tissue presents in its early 

■ 3 all the phenomena of true inflammation. Later the surfaces 

become denuded and assume a raw ham color; the Veins arc dis- 
tended, the border of the infected area i- raised and shows a loSS 

of substance in the depressed center the typical picture of an 

ulcer. Usually there i- a pronounced metallic taste present in the 

mouth. Arsenic penetrates verj deeply, destroying the -oft and 
hard tissues, which finallx results in true necrosis. In the early 



DEVITALIZATION OF THE DENTAL PULP 153 

stages the affection is not painful, but as soon as the deeper 
structures are reached severe pain is manifested. 

The treatment depends on the severity of the poisoning. Simple 
intoxication requires the immediate removal of the cause and mild 
antiseptic mouth washes. If necrosis has set in the affected parts 
must be thoroughly curetted with a large spoon excavator; if the 
bone has been sequestered it must be removed. Local anesthesia 
is usually serviceable for such work. The denuded surface is cov- 
ered with a suitable surgical dusting powder. Rigid antisepsis is 
of prime importance. A warm physiologic saline solution used at 
frequent intervals is indicated as a mouth wash. The local appli- 
cation of dialyzed iron as an arsenical antidote is indicated only if 
arsenic is present in substance on the tissues; after it is absorbed 
this solution is useless. 

Devitalizing Paste. 

1^ — Arsen. trioxid gr. xxx (2 frm.) 

01. caryophyl q.s. to make a paste 

Add a small amount of lampblack to color the paste. 

Devitalizing Fiber. 

1$ — Arsen. trioxid gr. v (0.3 gm.) 

Acid, tannic gr. ij (0.12 gm.) 

Phenol, liquefact q.s. to make a thin paste 

Sig. — Fine cross-cut absorbent cotton fiber is mixed with this paste and dried. 

Devitalizing Disks. 

1$ — Arsen. trioxid gr. xvj (1 gm.) 

01. caryophyl q.s. to make a thin paste 

Sig. — Cut small squares (1 to 1.5 mm.) of hard white blotting paper, saturated with 

the paste, dry in the open air and then put into a glass-stoppered bottle. 

Removal of the Pulp.— The removal of the anesthetized or devi- 
talized pulp should always be done under strict aseptic conditions. 
The preparation of the field of operation, the sterilization of the 
instruments and the general technic of the procedure is practically 
the same as that employed in the removal of gangrenous pulp 
debris as discussed under " Necrosis and Gangrene." 

To facilitate the disintegration of the devitalized pulp prior to 
its extirpation, pepsin or its substitute, papain, have been advo- 
cated as a means of digesting the dead tissue. Oakley Coles, 
Arkcevy and Harlan have recommended these agents for such 
purposes; they are rarely employed at present. The following 
combination was advocated by the late Harlan: 

I* — Pepsin gr. v (0.3 gm.) 

Acid, hydrochlor. dil gtt. j 

Glycerin q.s. to make a stiff paste 

Pack the paste into close contact with the dead pulp, seal the 
cavity and leave undisturbed for a week. The dead pulp will 
usually be found digested (liquefied) within that time. 



CHAPTER XVI. 
MUMMIFICATION OF THE DENTAL PULP. 

( Ilinical evidence confirms the statement that dead pulp tissue 
when left in a mot canal without being rendered permanently 
sterile will sooner or later cause disturbances from decomposition 
with all it^ M'<|iicl>. as a result of secondary bacterial invasion. 
Infective microorganisms may have been present in the diseased 
pulp; they may have been introduced at the time of treatment, 
or they may have reached the pulp tissue through the apical fora- 
men via the hlood current. Faisztl has experimentally demon- 
strated that hematogenous infection of the dental pulp is possible. 

Soon after the discovery of creosote in L830, as Flagg informs 
us, the dentists tried this agent for the purpose of preserving dead 
pulps left in situ, while Flagg himself employed a paste composed 
of phenol, oil of clove, sulphate of lime and acetate of morphin. 
In 1874 Adolph Witzel made an effort to solve the problem of pulp 
mummification by advocating the amputation method which was 
first practised by the late W. W. Allport. Witzel supposed that 
arsenous acid when placed upon an inflamed pulp would only destroy 
the diseased portion of this organ, while the remaining part, when 
separated by a slough, would preserve its vitality. The pulp stumps 
left in the canals were capped with an iodoform or a phenol cement 
of various compositions. In 1886 he changed his views and he 
referred to the pulp stumps as "being .shrunken to antiseptic 
threads,' 5 etc. Telchow, in L882, announced that he had found 
in Wickerscheimer's preserving fluid a medium with which he 
could successfully mummify dental pulps. This fluid is a complex 
mixture of alum, arsenic, various inorganic salts, methyl alcohol 
and water, and is used a> a preservative tor anatomic specimens. 
In 1888 Baume recommended borax for the purpose of embalming 
pulp stumps. The borax method, due to the very weak antiseptic 
power of this chemical, was a complete failure. In 1892 Herbst 

announced that he had found a method of pulp amputation which 

was simplicity itself. He placed upon the exposed pulp a mixture 

of 92 parts of Dative cobalt crude cobalt arsenate) and 8 parts of 
cocain hydrochlorid. After a few days, the coronal portion of 
the pulp was removed under aseptic precautions, the cavity steril- 
ized and tightly closed with soft tin. burnished into place by his 
rotation method. This is in reality the old way of treating pulps 



MUMMIFICATION OF THE DENTAL PULP 



155 



with arsenic as practised by our fathers. Even as late as 1888, 
Cunningham placed a pledget of cotton saturated with a mixture 
or arsenous acid in alcohol and oil of clove in the root canal of 
the molars for the purpose of preserving the pulp stumps. For a 
few years, teeth treated by this method would be quiescent, but 
after about five years 50 per cent or more had abscessed. In 
1892 the late W. D. Miller suggested a mixture of 3 parts of corro- 
sive sublimate and 1 part of thymol, compressed into small tablets 
which he used in about the same manner as Baume recommended 
for his borax embalming process. The success obtained with these 
tablets has been fairly satisfactory, the bluish-black discoloration 
of the teeth by the sublimate and the very frequent acute peri- 
cementitis following the treatment are serious objections. Sceder- 




Fig. 7G. — Schematic drawing of pulp-mummification. A, pulp stumps; B, mummi- 
fying paste; C, cement filling; D, amalgam filling. 



berg published an interesting account of his pulp mummifying 
process in 1895. He prepared a mixture of equal parts of thymol, 
alum and glycerin with enough zinc oxid to make a stiff paste. 
This paste has been employed with more or less success and from 
1896 to about 1902 the current literature is filled with reports and 
discussions on this interesting question. In 1898-1899 Bcennecken 
recommended a method of pulp mummification, using a paste con- 
sisting of cocain, thymol, formaldehyd, zinc oxid and glycerin. 
The success obtained with this treatment was apparently satis- 
factory, and his method has gained many friends. Brooks, in 
1898, offered chromic acid in conjunction with sulphuric acid for 
such purposes. In 1898 Julius Witzel published his experiments 
with formaldehyd and sulphuric acid, and a year later Lepkow T ski 
recorded his studies on the action of formaldehyd on pulp tissue. 



156 DISEASES OF THE DENTAL PULP 

Gysi, in 1899, experimented with a large number of drugs i<> be 
used as pulp stump preservatives and he finally arrived al the 
conclusion that the successful mummification depended upon the 
combination of an easy and a difficult penetrating antiseptic. 
Preiswerck, in L901, advocated a mixture of borax and eugenol 
with the addition of small quantities of tannic acid. Since then, a 
host of other publications have appeared, and especially since 
Gysi advocated a mixture of formaldehyd and cresol for the treat- 
ment of infected root c;inai>, this very mixture has also been rec - 

mended as a pulp mummifier. A most interesting monograph on 
this subject has been written by Boennecken, in which he treats 
the subject of pulp mummification from the clinical as well as 
From the experimental point of view. 

Pulp mummification has been advocated for such cases in which 
it is impossible to remove all of the pulp tissue. It should be 
remembered that this statement refers only to organized pulp 
tissue, viz., the pulp may have been in a normal state of health 
or in any stage of pulpitis except complete suppuration, prior to 
it-- devitalization, but it must never be employed upon a gangrenous 
pulp. It is an important dictum that a pulp suitable for this 
method of treatment must be recently devitalized by a cau-tic. 
It goes without saying that pulps which have been temporarily 
anesthetized by pressure or contact anesthesia have to be devital- 
ized by a caustic before becoming eligible to the process. 

It is an imperative law of modern conservative dentistry that 
all available efforts should be made by the conscientious practi- 
tioner; to remove, if possible, all of the dead pulp tissues. Even if 
we are able to mummify a devitalized pulp in its entirety, this 
method should not be practised indiscriminately as it is antagon- 
istic to one of the fundamental concepts in surgery which teaches 
us to remove all necrosed tissue, and its general practice may 
create a tendency to carelessness and imperfect work on the part 
of the operator. As a consequence, this method of treatment has 
been discarded at present by the practitioners in the United Stat*-. 
The chief objection raised by the advocates of the mummifying 
principle against the generally accepted method of complete extir- 
pation hinges primarily on the supposed inability on the part of 
the operator to remove all of the pulp tisane from certain root 
canals due to their peculiar anatomic structure. This objection 

is largely nullified by the intelligent use of a properly selected 
instrumentarium in conjunction with well-defined roentgenograms 
of the respective tooth. 'The objection to the expenditure of time 
as required \'^v this tedious operation should not receive any con- 
sideration 1>\ the conscientious practitioner. However, in such 
\cn rare cases where it is utterly impossible to remove all of the 
pulp tissue, i. '.. principally in multi-rooted teeth, and where it is 



MUMMIFICATION OF THE DEXTAL PULP 157 

essential to save the tooth, the application of the mummifying prin- 
ciple may be justified. The pulps of the deciduous teeth are 
especially amenable to this mode of treatment. 

The process of mummification of pulp tissue is based upon certain 
fundamental principles which have to be fully recognized in order 
to insure success. Wrong diagnosis of prevailing conditions of the 
pulp, faulty technic in the application of the various medicinal 
agents and the use of inadequate drugs are largely responsible for 
the failure obtained with this procedure. Without entering into 
a detailed enumeration of the various compounds which have been 
used experimentally, let it suffice to say that thymol answers this 
purpose well. It is a phenol-like body of greater antiseptic strength 
than pure phenol and is only very slowly soluble in water. As this 
compound does not possess enough "body," some inert material 
should be added thereto, such as zinc oxid or a bismuth salt, etc., 
and enough cresol or some other suitable fluid antiseptic to form a 
substantial paste. A suitable mummifying paste may lie prepared 
according to this formula: 

Thymol 10 parts 

CresoJ 10 " 

Zinc oxid -enough to make a stiff paste. 

The thymol is dissolved in the cresol by trituration and enough 
zinc oxid is added to make a still' paste. 

(ivsi's triopaste has the following composition: 

Cresol 10 parts 

Creolin . . . 20 " 

Glycerin ... 4 " 

Trioxymethylen . 20 " 

Zinc oxid 66 " 

As we have stated above, only such eases are amenable for this 
method of treatment in which the pulp is not gangrenous. The 
pulp is devitalized with arsenous trioxid in the ordinary way. The 
latter should be left in position for about two to three days, depend- 
ing upon the vascularity of the pulp. Under the strictest aseptic 
precautions the coronal portion of the pulp is drilled out with a 
round bur and an effort is made to remove from the canals as much 
of the pulp tissue as possible. The cavity is repeatedly flushed 
with sterile water and dried with bibulous paper. 

A concentrated solution of (50 per cent) zinc chlorid in distilled 
water is now allowed to flow into the root canals so as to thoroughly 
impregnate the pulp remnants. After a few minutes the excess 
fluid is removed with sterile paper cones and a small quantity of 
mummifying paste is worked into each canal, pressed into position 
with a tightly rolled pellet of cotton, and the remainder of the root 
canal and the pulp chamber are filled with cement. 



158 DISEASES OF III!-: DENTAL i'ULP 

If the aseptic technic of pulp mummificatioE Is applied strictly 
according to the above discussed modus operandi and if careful 

attention is paid to the correcl diagnosis of the existing condition 
of the pulp, success will in the majority of cases be assured. Experi- 
mental work as carried out by Cnendet 1 with Gysi's "triopa 
revealed the fad that within a period of from four to ten months 
in 92 per cent of the cases the root canals remained sterile. No 
disturbances of the periapical tissues were observed. However, we 
should he mindful of the fact that observations extending over a 
period of ten months do not Furnish Sufficient proof to render final 
judgment about a therapeutic procedure of the above discussed 
nature; at least fi\c years' time and many individual cases are 
required to substantiate clinical results. 

1 [naugural Dissertation, Zurich, L920. 



CHAPTER XVII. 
NECROSIS AND GANGRENE OF THE DENTAL PULP. 

Synonyms.— Death and putrefaction of the dental pulp, necrosis 
et gangrcena pidpce. 

Definition.— Death of the dental pulp from any cause and simul- 
taneous or subsequent infection resulting in putrefaction. 

Etiology.— Death of the pulp may be caused by any one of the 
numerous disturbances as outlined under Etiology, or it may be 
artificially produced by a toxic agent, usually arsenic trioxid. 
Gangrene of the pulp is the result of secondary putrefactive changes 
occurring in the necrotic tissue. Necrosis and gangrene are pri- 
marily caused by a bacterial invasion, usually a streptomycosis 
of a mixed type, arising as a sequence of existing dental caries. 

Varieties.— Clinically, necrosis and gangrene of the dental pulp 
may manifest themselves as any one of the numerous varieties as 
discussed below. 

Clinical Pathology.— The clinical manifestations of necrosis and 
gangrene depend primarily upon the respective state of the dead 
pulp. True necrosis without infection in an otherwise sound tooth 
usually presents no visible signs of disarrangement, except a possible 
discoloration of its crown and it causes no inconvenience to the 
patient. If the pulp chamber is exposed putrefaction of the dead 
pulp will reveal itself to the patient by foul odors and a bad taste. 
As soon as the products of the putrefactive process penetrate into 
the periapical tissues, marked disturbances arise which manifest 
themselves in the majority of cases as an acute alveolar abscess 
which at some future period may assume a subacute or a chronic 
type. If the periapical infection is of a very mild type the vital 
reaction of the disturbed pericementum institutes a process of 
defense resulting in a chronic proliferating pericementitis, usually 
referred to as a granuloma. Should this granuloma contain 
epithelial cells, the mild irritation may cause this latter tissue 
to proliferate in all directions and finally form a complete capsule. 
Degeneration of the newly formed epithelial goblet cells occurs 
and their contents, i. e., mucus, fat and other products of decom- 
position collect in the interior of the granulomatous sack and by 
pressure from the accumulated fluid the surrounding bone is 
absorbed and a radicular cyst is the usual sequence. 

A clear conception of the chemistry and the bacterio-pathology 



61 



DISE i SE& OF THE DENTAL l'( LP 



of the various manifestations as they occur in dead pulp tissue 
i- of the utmost significance as related to the future treatment of 
the disturbance, hence a detailed discussion of this momentous 
phase of the pathology of infected root canals is of vital import- 
ance to the clinical practitioner. 

The dental pulp Is composed of connective tissue, uerves and 
bloodvessels. All animal tissues are essentially built up of cells 
and the constituents of these cells consist of proteidogenous matter, 
lipoids, salts and water. Only a very few elements enter into their 

make-up, i. e. f nitrogen, oxygen, carbon, hydrogen, sulphur and 
very little phosphorus and iron. The tissues containing nitro- 
gen arc referred to as nitrogenous substances, or protein-, while 
non-nitrogenous substances are spoken of a- carbohydrates and 



(mtA 






^^B^^^ ^^H 








^n 



1 1. 



( iangrcne of the dental pulp 



fats. The normal pulp tissue is composed principally of proteido- 
genous material, and so far no carbohydrates or free fats have 
heeii isolated from it. The proteins are the most complex bodies 

known to chemistry; they are usually colloidal in their nature, 

and are composed of molecule- that differ widely in their weight 

and size. The average protein molecule approximately furnishes 
the following constituents: Carbon, 51 to 55 per cent; oxygen, 

20 t<> _' I pei - cent; nitrogen, 15 to 17 per cent; hydrogen, 6.8 to 
7 :.\ per cent; sulphur, 0.3 to 0.5 per cent and very -mall quantities 

of phosphorus and iron. The protein- ina_\ he decomposed l>\ 

acids, alkalies and ferment-. Ihese latter substances arc found 
extracellularlj in the digestive juices and intracellular^ where 
ihe\ become manifest in autolysis; the} are produced by bacteria. 
In the decomposition of the pulp we are principally concerned with 



NECROSIS AND GANGRENE OF THE DENTAL PULP 161 

the intracellular (autolytic) and bacterial enzymes. The ferments 
which are secreted by the leukocytes during the various inflamma- 
tory processes within the diseased pulp are the digestive agents, 
as Kantorovicz has shown. Death of the pulp, i. e., necrosis, is 
the precursor of pulp decomposition, i. e., gangrene. 

Whenever healthy tissue becomes irritated by physical or chem- 
ical (including bacteria) agents to such an extent as to cause intense 
disordered cell nutrition, death of the cells results. This process 
is known as necrobiosis. A pulp may accidently die of its own 
accord through any of the above causes, or it may be intentionally 
killed by a caustic, usually arsenic trioxid. 





a 


b 




% 


J 
1 


a 


C 




i 



Fig. 78. — Action of ferments produced by the leukocytes in diseased dental pulps 
(Kantorovicz) : a, healthy pulps; h, pulps with partial acute pulpitis; c, pulps with 
total acute pulpitis; <l, pulp with supurative pulpitis; e, pulp with an abscess contain- 
ing pus. The center contains granulomas obtained from roots. 



In general pathology four varieties of necrosis are usually recog- 
nized : 

1. Coagulation Necrosis. — This form of necrosis results from the 
coagulation of fluids that have entered into or are present in the 
pulp, and that contain coagulable substances, L e., the soluble 
colloidal material is transformed into insoluble modifications. The 
change of fibrinogen into fibrin is an important factor in this pro- 
cedure. The pulp assumes a dry, firm appearance, and is usually 
of a yellowish color. When blood enters into the root canal after 
the removal of a coagulated pulp, it usually becomes quickly 
clotted. Coagulation necrosis may be caused by heat, phenol, 
11 



162 



DISl OF THE DENTAL PULP 



/--"' 



corrosive sublimate and other chemicals, and it is rather seldom 
met with in the ordinary cases of death of the dental pulp. 

2. Liquefaction or CoUiquation Necrosis, This type of necrosis 
occurs principally in the central aervous system; it- etiology is 
do! quite clear, and probably edematous infiltration and enzyme 
action have much to do with it. It may be caused by the action 
of chemical substances resulting in aseptic suppuration. True 

suppuration should not be confounded with it. It 

is very rarel) observed in the dead pulp. 

.'L Caseation Necrosis. This term i- applied to 
a type of coagulation necrosis which resembl< 
emulsion of fat and water, and has the appearance 
of soft cheese. The coagulum is made up of pro- 
tein derivatives, considerable quantities of fat and 
water, etc. Fatty defeneration of the pulp as a 
whole is rarely observed. The action of proteolytic 
enzymes is probably largely responsible for these 
changes. Caseation is mosl frequently found in 
'jM pulp decomposition. 

1. Fat Necrosis. This specific type of necrosis 
is restricted to fat tissue and is characterized by 
a splitting of the fat into fatty acids and glycerol. 
As the normal pulp does not contain free fat. fat 
necrosis is probably never observed in it- pure form 
in this organ. 

Gangrene. Gangrene i> the result of secondary 
putrefactive changes, and it results from the dual 
action of proteolytic enzymes and putrefactive 
organisms. Two forms of gangrene are usually 
recognized in general pathology, i. e., moist and 
dry gangrene. Moist gangrene depends on the 
presence of water, while the absence of water de- 
notes dry gangrene or mummification. In dr 
grene nearly all further changes cease, while in the 
moist form the autolytic changes continue. A 
totally gangrenous pulp presents a mass of de*bris 
in which lime concretion-, fat droplets, Crystals 
of fatty acid-, of hematoidin and of triple phos- 
, " r,n " 1 h - v :i i ,u - phates, numerous bacteria, and various pigments 

tri«l pulp upon ' . II- -ill nm I . I 

cuituremedhim. are the only discernible elements. 1 he tat drop- 
lets are partially produced by fatty degeneration 

of the myelin -heath- <-f the nerve liber- ami partially by dis- 
integration of the cell protoplasm and dead bacteria. 'The latter 

Mi-m- apparently contain fat a- a metabolic constituent in 
the form of lipoids. In the great majority of cases of pnlp dis- 
integration progressive moist gangrene i- predominating. In clin- 
ical practice complete moist [gangrene of the pulp i- 



not always 



NECROSIS AND GANGRENE OF THE DENTAL PULP 163 



found, and the latter organ may be partially or totally gan- 
grenous. In partial gangrene one part of the pulp may be 
totally putrescent, while the other part may be still in a 
state of severe inflammation. A fairly distinct line of demar- 
cation may be observed between the dead and the inflamed part 
of the pulp. Through necrobiotic and secondary putrefactive 



changes the entire pulp will finalh 
When dead protein material is 
subjected to the action of bacteria 
and ferments, the process is known 
as putrefaction. Putrefaction in 
its early stages is principally a 
process of hydrolysis and oxida- 
tion, and closely resembles tryp- 
tic digestion— that is, certain fer- 
ments, enzymes and products of 
bacterial activity are concerned 
in the cleavage action of the pro- 
tein molecules, a process which is 
closely allied to the changes occur- 
ring in the intestinal tract. The 
preliminary action of the proteo- 
lytic enzymes on the dead protein 
molecules results in the formation 
of albumoses, peptones and poly- 
peptids. Further decomposition 
is productive of various amiiio- 
acids, /'. c, fatty or aromatic acids 
in which one or two of the hydro- 
gen atoms have been replaced by 
a basic ammonia radical. It is 
claimed by Czapek and Emmer- 
ling that these amino-acids furnish 
excellent nutritive material for 
bacteria. The amino-acids are 
further decomposed by the elimin- 
ation of ammonia and by the 
splitting off of carbon dioxid, respectivel 
oxylization, occurs. 



become totally gangrenous. 



Pigment. Sulphur + hemoglobin. 




C0 2 , NH 3 ; 
H2O and HjS. 



Aromatic and 
fatty prod- 
ucts. 

Ptomains. 



Peptones. 



Fig. SO. — Diagram illustrating the 
more complete decomposition of the 
pulp at its coronal end. (Burchard 
and Ingles.) 



iy, deamination and decarb- 
In the ammonia elimination the end-products 
are found to consist of free fatty acids, corresponding to the amino- 
acids from which they are derived, L e. t acetic, propionic, butyric, 
valerianic, caproic and a-amino-valerianic acid and of the aromatic 
acids, i. e., phenyl-propionic, hydro-cumaric, skatol-acetic and 
succinic acid, etc. The further oxidation of the various fatty 
and aromatic acids results in the formation of many paraoxy- 
acid compounds, i. e., paracresol, phenol, etc. Sulphur is set free 



Hi! DISEASES OF THE DENTAL 1't LP 

during the breaking-down of protein substances; partially it unites 
with free hydrogen to form hydrogen sulphid, and partially with 
free < \ groups to form various sulphocyanids of a less toxic nature. 
In the course of their decomposition the aromatic products furnish 
indol and skatol; indol finally combines with tree sulphuric acid 
and forms indiean. The latter substance furnishes an Important 
diagnostic indicator of the process of putrefaction. 

The products of decarboxylation are amins i tyramin and hista- 
min) and diamins (cadaverin and putrescin) which latter group is 
included among the so-called ptomains. The aromatic and fatty 

acids, hut especially skatol and indol, are largely responsible for 
the Nile fetid odor which accompanies the putrefaction of protein 
material. The final products are water, ammonia, hydrogen, 
hydrogen sulphid and carbon dioxid. Tin- lasl stage of complete 
decomposition Is rarely reached in the putrefaction of pulp tissue. 
The reaction of a putrescent pnlp is probably always alkaline, 
and the necessary carbohydrates which would furnish acids as by- 
products of Fermentative changes are absent. The acids that are 
formed during the decomposition of protein matter are readily 
neutralized by the many basic materials that are created simul- 
taneously with these compounds. It may be observed, however, 
that in the union of two amino-acid, an acid radical and a basic 
radical are liberated, which, under certain conditions, give rise to 
amphoteric reactions. 

The bacterial phase of pulp decomposition is of even greater 
clinical significance than its chemistry. Hand in hand with the 
progress of chemical decomposition; the bacteria that are present 
in the pulp tissue give rise to many substances, i. e. f toxins, endo- 
toxins, bacterial proteins and indirectly ptomains. 

Mayrhofer' furnishes the following statistics concerning the 
presence of microorganisms in dead pulp tissue: 

Number ol 
« frganiame Found. timea found. 

ptOCOCCJ 70 

91 reptococci and rods it 

Streptococci and staphylococci it 

ptococci, staphylococci and rods 10 

: •'■ "' »cci and \ easl cells 5 

>u. ptococci, rode and yeasl cells : - 

■li\ 1<>< SOCCi 

■h\ lococci and rods . i 

\e 2 

Concerning the presence of these various microorganisms in 
open and closed putrescent root canal-. Mayrhofer obtained the 

follow ing data : 

1 Principien «I«t Pulpagangran, 1909. 



NECROSIS AXD GANGRENE OF THE DENTAL PULP 165 

Number of times Number of times 

found in 53 cases found in 51 cases 
of open root of closed root 

Organisms found. canals. canals. 

Streptococci 27 31 

Staphylococci and rods 18 6 

Streptococci and staphylococci 3 1 

Streptococci, staphylococci, rods .... 1 5 

Streptococci and yeast cells 1 

Staphylococci 1 2 

Staphylococci and rods 1 

Rods 1 G 

The influence of bacteria, per se, is of little importance as far as 
pathogenic disturbances are concerned, and the harm that is 
caused by the presence of these organisms is due to the many 
chemical products that result in one way or another from their 
metabolic processes. The many offensive products that accom- 
pany putrefactive changes are attributed to anaerobic conditions, 
while in the presence of oxygen usually less ill-smelling compounds 
arc formed. Some observers claim that only strictly anaerobic 
bacteria are concerned in the putrefaction of proteins. The auto- 
lysis of leukocytes depends principally upon obligate anaerobic 
microorganisms. Suppurative pulpitis and gangrene, according to 
Idman, are primarily dependent upon obligate anaerobic bacteria 
and they play a most important role in these processes. The 
streptococci and the staphylococci are both aerobic organisms, 
and only optionally anaerobic. The presence of malodorous com- 
pounds is readily perceived by entering into a closed root canal 
containing a putrescent pulp. 

The poisonous chemical products of bacteria, according to Wells, 
may be conveniently divided into ptomains, toxins, endotoxins 
and bacterial proteins. The ptomains, i. e. } soluble basic nitro- 
genous substances, resemble vegetable alkaloids and are derived 
from protein material decomposed under the influence of enzymes 
and of putrefactive bacteria. For some time past it was believed 
that ptomains were the cause of infectious disease, but it was soon 
found that they could be removed from cultures of pathogenic 
bacteria without destroying the poisonous nature of the latter. 
At present the chemistry of bacterial intoxication is more clearly 
worked out, and, as a consequence, ptomains are of much less 
interest than they were twenty years ago. In decomposing pro- 
tein material quite a large number of ptomains are more or less 
present as a result of the cleavage action of enzymes and other 
hydrolytic agencies. Cadaverin, putrescin, sepsin, musearin, leucin, 
tyrosin, neuridin, etc., are some of the more important representa- 
tives of this interesting group. Ptomains do not act as specific 
poisons, but many produce diseases when taken into the body with 
the food in which they have been produced by bacterial activity. 
It is claimed that pathogenic bacteria present in living tissue can 



166 



DISE VSES OF THE DENTAL PI LP 



doI produce sufficient ptomains to seriously affecl the health of 
the individual. Moist gangrene of the i>ul|) is a ready source of 

ptoinain format ion. 

( Vitaiii pathogenic bacteria produce definite synthetic poisonous 
substances of a specific nature, /. e, s the toxins. Toxins arc the 
secretions of cells, and arc readily taken up by the surrounding 




Fio. 81. \ arioua types of bacilli isolated from gangrenous dental pulps. I [dman.) 



tissues. The intense poisonous nature of these toxins is respons- 
ible for the chief symptoms which we recognize in infectious diseases. 
The bacillus of diphtheria and tetanus are know n to secrete typical 
toxins. These toxins are always of the same poisonous nature, ne 
matter how or where they are obtained, while the ptomains vary 
with the nature of the substances from which they are derived. 
Toxins are \cr\ labile substances, and they are readily destroyed 



NECROSIS AND GANGRENE OF THE DENTAL PULP 167 

by heat, direct sunlight and oxygen. Antibodies or antitoxins can 
be prepared against toxins, but not against ptomains. As very 
few bacilli are known that produce specific toxins, it is plain why 
so few true antitoxins have been artificially prepared. 

Again, bacteria may produce poisons within their own cell 
bodies; they are not usually secreted by the cells, but are also 
specific in their poisonous nature. These bodies are known as 
endotoxins. As yet no antitoxins have been prepared against 
endotoxins, and, as most bacterial diseases are caused by endo- 
toxins, the preparation of sera has been greatly retarded, and 
consequently, immunization against many infectious diseases is 
apparently impossible. Furthermore, bacteria contain poisonous 




Fig. 82. — Smear obtained from suppurating pulp. Mixed infection; 1 : 1000. 

(Miller.) 

materials which form an integral part of their protein constitu- 
ents. These poisonous materials are not soluble, and apparently 
do not produce diseased conditions. The bacterial substances 
themselves may, however, produce inflammation and pus, or even 
necrosis, when injected into living tissues. These substances are 
called bacterial proteins. 

Diagnosis.— In complete necrosis or gangrene of the dental pulp 
when confined to an open root canal usually no painful symptoms 
are manifested. As soon as disturbances of the periapical tissues 
occur, which were primarily the sequences of pressure from con- 
fined gasses produced by the decomposition of pulp tissue, marked 
progressively increasing pain with all the additional symptoms of 



168 DISE iSES OF THE DENTAL l'i LP 

an acute inflammation of the pericementum are to be observed. 
The pulp has lost it- sensation completely; an explorer may be 
inserted into the root canal without causing a painful response. 
Only in partial necrosis or gangrene i^ pain fell as soon as the line 
of demarcation Is reached. The color of the tooth i> markedly 

altered, i. i ., the tooth has lost its life-like luster and it may have 

changed from the normal to any shade toward dark gray. Trans- 
illumination Furnishes a dull shadow picture, while temperature 
changes are not revealed by dead pulp tissue. The percussion 
sound of a tooth containing a necrosed or gangrenous pulp is nega- 
tive. The faradic current produces no response whatsoever from 
a dead pulp; however, great care should be observed in not touching 
a metallic filling with the electrode or placing the latter too near 
the gum line, otherwise a painful reaction may be obtained. 

If the pulp chamber is exposed the patient usually complain- of 
a had taste and foul odors arising from the decomposed pulp and 
from putrescent food particles having lodged in the cavity. Com- 
plete loss of sensation and the typical odor of putrefaction arc 
respectively the pathognomonic signs of necrosis and gangrene of 

the dental pulp. 

Prognosis. Necrosis and gangrene of the pulp indicate dead 
tissue, consequently treatment cannot be considered. A favorable 
prognosis of the involved tooth, however, may usually he rendered, 
as in most instances suitable treatment of tin* infected root canal 
and its subsequent filling will restore the tooth to proper useful] 

Treatment. The most serious question that confronts the dental 
profession today and for that matter has also confronted it in 
the past is that which is involved in establishing absolute steril- 
ity of an infected root canal. The disposal of this problem in a 
truly scientific manner necessitates the determination of the estab- 
lished sterility by a bacteriologic or microscopic examination in 
each individual case. While the writer realizes that the carrying 
nit of such procedures in the average dental office of today will 
meet with numerous difficulties, due to the fact that the older 
members of our profession have not had sufficienl training in these 
directions, nevertheless, there exists no valid reason why it should 
not be done by the recent graduate who has received adequate 
instructions in laboratory technic, or through a bacteriologic 
laboratory. The time i- not far distant when the public will 
demand a laboratory diagnosis of serious root canal infections for 
the same reason that a bacteriologic examination of a diphtheritic 
throat i> demanded at present. Since the sequences of imperfect 
root-canal sterilization in .the form of focal infection resulting in 
metastatic disturbances of distant organs are of common occur- 
rence, it iiiu-t follow that the current method- of diagnosis of 

sterility of a primarily infected root canal arc inadequate. 



NECROSIS AND GANGRENE OF THE DENTAL PULP 169 

From a logical deduction based upon the above discussed path- 
ology of infected root canals it is evident that its treatment resolves 
itself into three definite phases: The mechanical, the chemical 
and the therapeutic procedures. Mechanical manipulations are 
intended to dispose of the debris of the dead pulp and to assist 
in the enlargement of the canal. Chemical procedures are pri- 
marily applied for the purpose of facilitating the removal of obstruc- 
tions, and therapeutic applications are utilized to overcome septic 
condition. 




Fig. 83. — The Flaherty molten metal sterilizer. 



Sterilization.— It should be an inflexible rule with the operator 
to perform all root-canal work under strict aseptic conditions. 
The teeth which are to be placed under rubber dam should be 
cleaned with cotton pellets and water and the gingival edge is 
touched with Talbot's iodin solution. The rubber dam is to be 
thoroughly washed with hot water and soap. The exposed teeth 
and the adjacent dam is washed with alcohol and dried with bibu- 
lous paper. A root canal should only be entered into with abso- 
lutely sterile broaches, absorbent paper or cotton points, gutta- 
percha cones, root canal pluggers, etc. All long-handled instru- 
ments should be sterilized by boiling in the usual way in any one 



170 



\SES OF THE DENTAL PULP 



of the ordinary sterilizers, while the delicate root-canal instru- 
ments, such as broaches, files, reamers, etc., may be sterilized by 
dr\ heat, by using the Flaherty Molten Metal sterilizer or by 
chemical mean- as they lose much of their rigidity by boiling in 
water and, consequently, they readily break. The Flaherty Mol- 
ten Metal sterilizer is a useful apparatus for sterilizing root-canal 
instruments, absorbent point-, etc. According to laboratory t< 
as carried out in various institutions, metal broaches, etc., are 
rendered sterile in five seconds, while paper point- and other 
porous objects require ten seconds when dipped into the molten 




Fig. 84. Dry heat steriliser. Automatic control makes it possible to maintain 
any degree of temperature from 200 e F. to 350 F. for an indefinite period. A 
temperature of 230 F. \\ ill sterilize in ten minutes, with >i higher degree «>f tempera- 
ture less time is required, and with a lower temperature the time must be lengthened 
proportionately. Especially useful for cotton, absorbenl points, gutta-percha a 
napkins, dressings, etc. ( k>olid| 



metal. The temper of the broaches, etc., is not altered by the 
short exposure to the metal hath. A simple and satisfactory 
chemical method of sterilization consists iii immersing the broaches, 
files, reamer.-, etc., in a concentrated (10 per cent) solution of 
-odium hydroxid for fifteen minutes. This alkaline solution 
possesses the additional advantage of dissolving organic d€bris 
entangled in the barbes of the broaches. A suitable solution is 
made by dissolving the content- of a can of commercial sodium 
hydroxid 1 in a gallon of tap water. A heavy precipitate occurs 

I rude -"lium hydroxid is commercially referred to as "potash" or "lye* 1 and 
i in tin cans containing aboul 12 oui sufficiently pure preparation f<>r 

tl.w abo\ « purpt 



NECROSIS AND GANGRENE OF THE DENTAL PULP 171 

which is allowed to settle. A glass covered jar of about one-half 
pint capacity is dipped with its neck into melted paraffin to the 
extent of about one inch and then filled with the solution just 
below the paraffin coating. The mechanically cleansed broaches, 
etc., are placed in a Gooch porcelain crucible with perforated 
bottom and are immersed in the soda solution. As sodium 
hydroxid dissolves aluminum, handles made of this metal must 
be handled with care as it is very caustic. After remaining in the 
solution for about fifteen minutes, the crucible is removed with 




Fig. 85. — Steam chest sterilizer. Moist heat may be obtained varying from 190° F. 
to 215° F. and can be maintained for an indefinite period. It is necessary to 
maintain this temperature at least thirty minutes and is safer to sterilize three suc- 
cessive days before using the materials under sterilization. (Coolidge.) 



pliers, drained off through the perforated bottom and transferred 
to a second similar jar (not paraffined) containing a glycerin- 
alcohol solution, i. e., 1 ounce of glycerin to 7 ounces of alcohol. 
The root-canal instruments are transferred with sterile pliers to 
sterile glass dishes (Petri dishes, etc.). The sterilized long-handled 
root-canal instruments may be readily kept for convenience in 
suitable bottles. The tips of shears, pliers and other instruments 
of a similar character and diagnostic wires may be quickly sterilized 
by dipping in alcohol and burning off in the flame. 

A convenient and simple sterilizer for absorbent paper points 



172 



DISEASES OF THE DENTAL PULP 



;iikI gutta-percha cones has been recently devised l>\ the writer. 
A colorless screw-cap bottle of about I ounce capacity is provide I 
with ;i piece of thick cotton foil of about one inch in length, which 
is fastened to the interior of the cap with sealing wax. About 
5 drops of dichloramin-T solution (5 per cent I are placed upon the 
lower end of the roll. The chlorin compound i^ renewed about 
once a month. The paper, cotton or gut ta-perelia point- are placed 
in the bottom of the dry bottle, the screw cap is put into position 
and the permanent sterilizer is completed. The exposure of the 
clear glass bottle to the light rays causes a very slow liberation of 
chlorin. The gutta-percha cones and paper points as obtained in 
sealed packages from the manufacturers are usually sterile and 
the little deviee as suggested is primarily intended to preserve 
their sterile condition. The efficiency of this simple sterilizer has 
been repeatedly tested by plating out the points; they have always 





Fio. Btt. ". Paper-cone -t iriliser; '-. Gutta-percha point steriliser. 



been found to he absolutely sterile. For general office use, a 
covered glass compartment tray provided with a layer of cottonoid 
in it- glass top upon which a lew drops of dichloramin solution 
are placed in monthly intervals, i^ very convenient. This dish is 
known a- the "Mynol Compartment Tray." As a most service- 
able means of holding the necessary drugs, sterilized broaches, 
etc., the writer has suggested an aseptic medicament tray. The 
large compartment of this tra\ i- filled with the glycerin-alcohol 
mixture and with sterile pliers the necessary instruments are 
transferred to this compartment and arc kept immersed while 
w orking on the tooth. 

Mechanical Preparation <>/ fin l{<><>t Canal. The successful treat- 
ment of ;i root canal depend- primarily upon the possibilities of 
gaining tva- access to the pulp chamber and to the mouth of the 
canal. Obstructing wall- and angles of enamel and dentin should 



NECROSIS AND GANGRENE OF THE DENTAL PULP 173 

be cut sufficiently until free access to all canals on straight lines is 
secured. It is a good policy to sacrifice a little tooth structure in 
the beginning which may obstruct a root canal than to try and 
manipulate broaches around curves and angles. Not too much 
emphasis can be placed upon this important step of the operation 
as many of the failures of root-canal treatment are directly trace- 
able to neglect of this initial procedure. 




8 ,„£«.„!„ 



Fig. 87. — Calcification of the permanent upper teeth. I Hopewell-Smith.) 

An intimate knowledge of the anatomic structure of the indi- 
vidual teeth, especially in regard to the relationship of their pulps 
to the surrounding dentinal walls is imperative. One should be 
mindful of the fact that the dental pulp is the remnant of the original 
formative organ of dentin. In single-rooted teeth, i. e., incisors, 
canines and some of the premolars, the pulp occupies the central 
part of the tooth as regards its long axis, while in multi-rooted teeth 
with occasional exceptions in the third molars each root contains 




Fig. 88. — Calcification of the permanent lower teeth. (Hopewell-Smith.) 



an individual part of the pidp in the same axial relationship, but 
their pulp chamber is single, ?'. e., it combines the various root 
pulps into a single coronal portion. 

The size of the pulp depends largely upon the age of the respec- 
tive individual; with increasing age a diminution of its bulk is to 
be observed. In the young an intimate knowledge of the stage of 
calcification of the respective tooth is imperative as the size of the 



171 



DISEASES OF THE DENTAL n LP 



pulp and of the apical foramen within certain periods of age varies 
greatly. Up to middle age the volume of the pulp remains Fairly 
constant while in the agedjnew irregular masses of dentin are 



I ii -i Seoond 
incisor incisor Canine 



First premolar 
Second premolar 




Third 

molar 



I molar 
Pint molar 



Se< ond premolar 

First premolar 



1 "■■ B9 Horizontal sections of the maxilla and mandible cut a little beyoi 
'"• margin of the alveolar process, showing the forma and positions of tl 
ili« \ arious teeth. I ( ■ 



deposited within the canal which may be the cause of senile atrophy 
of the pulp and usually of more or less complete obliteration of the 
pool canals. 
In general, it may be stated thai the pulps of the incisors and the 



NECROSIS AND GANGRENE OF THE DENTAL PULP 175 

canines resemble slightly depressed cones, ending in a thin thread 
near the foramen, while in the crown they may reach to within a 
third and occasionally to one-half of that portion of the tooth. 
In the crown the pulps of the incisors end in three slight eminences, 
while the coronal part of the pulps of the canines present single 
sharp points. 

The pulps of the upper first premolars present in their coronal 
portion two distinct horns corresponding to the two cusps; the 
lingual horn is the smaller of the two. The buccal horn often 
extends within the center of the crown while the lingual horn rarely 
passes beyond the neck of the tooth. The bucco-lingual diameter 
of the pulp is larger than the mesio-distal diameter with a slight 
depression near the center. The two root canals of this tooth do 
not always separate within the pulp chamber; the isthmus is often 
found in the first third of the root or even at its center. The upper 
second premolar is usually single rooted and consequently only one 
canal is observed. Frequently, however, a division of the pulp 
may occur within the upper third of the root. The diameter of 
the pulp is much wider bucco-lingually than in its mesio-distal 
direction. 

The pulps of the upper molars, especially in young individuals, 
usually show a pronounced coronal portion corresponding to the 
three and, rarely, to the four cusps of its crown. The coronal 
portion of the pulp rarely occupies more than a third of the crown. 
The pulp canal of the lingual root is the largest of the three canals; 
occasionally it may be bifurcated near its apical end. Of the two 
other canals the disto-buccal canal is the smallest and in conformity 
with the outline of the root it is frequently curved. 

In the third upper molars the pulp canals follow the general 
outline of the very variable number of roots. But as this tooth has 
a tendency to be most irregular in size and shape the number of 
root canals differs greatly. Frequently in the single-rooted third 
molars only one large central canal is observed which may show 
several bifurcations near the apex. 

The pulp of the lower incisors and canines differ little from those 
present in the same teeth in the upper jaw. In most instances, 
they reach far up into the crown. Occasionally, a bifurcation of 
the root canal is to be observed in the lower canines. 

The lower premolars are single-rooted teeth and usually they 
are regular in outline. Frequently the pulp presents two horns, of 
which the buccal is the largest. The greatest diameter is observed 
near the neck of the tooth in a bucco-lingual direction. Near the 
apical end the pulp often tapers to a fine thread. 

The coronal portion of the pulps of the lower molars corresponds 
to the general outline of the crowns of these teeth; usually four 
horns are observed. The pulp canal of the mesial root frequently 



176 DISEASES OF THE DENTAL J'l LP 

divides into a buccal and a lingual portion while the distal root 

presents li b1 Instances a single well-developed canal. The 

greatest diameter of these canals lies in a bucco-lingual direction. 

IftfTir 

ontw 

I i'.. 00 Diagram of longitudinal sections of permanent teeth Bhowing the t] 
u bich t he pulpa occupied. 

I he pulp canals <»t the lower third molars arc very irregular in 
outline; in single-rooted teeth a large pulp cavity with a single or 
several canals maj be observed. In the latter instance these canals 
frequently ramify . 

Man} anomalies of the normal topographic anatomy of the dental 



NECROSIS AND GANGRENE OF THE DENTAL PULP 177 

pulp may be observed. Among the principal malformations may 
be mentioned numerous branches of the pulp which are directly 
corrected through lateral canals with the pericementum. These 
ramifications are especially numerous near the principal foramen; 
five or even more such branches have been observed. Connecting 
bridges within the root canal which contain pulp tissue are often 
encountered. Additional roots with root canals and, consequently, 
branches of the pulp, are by no means rare abnormalities; usually 
they may be diagnosed from a good roentgenogram. 

9 9 9 * b g 



* A t » V 

Fig. 91. — Diagram of cross sections of permanent teeth at various points. 

The successful removal of the debris from a root canal depends 
primarily upon its size; large canals are naturally more accessible 
than the small, tortuous canals, especially those of the mesial roots 
of the lower molars, the buccal roots of the upper molars and those 
of the upper first premolars. Curvatures of the roots and the 
presence of secondary dentin materially increase the difficulties. 
During the process of enlarging the canals numerous complications 
may arise, among which the packing of debris into the apical 
regions of the very fine canals, cutting ledges into the walls of a 
curved canal and breaking the tip of a broach near a curve are 
relatively common occurrences. At the beginning of the operation 
only the very finest picks or pathfinders should be employed which 
may be followed with barbed broaches. Binding of the broach 
12 



17s DISEASES OF THE DENTAL PULP 




of the pulp chambers of permanenl teethal variousap 



NECROSIS AND GANGRENE OF THE DENTAL PULP 179 

within the canal must be rigidly avoided as breaking of this delicate 
instrument by applying undue force is almost certain to occur. If 
a ledge is cut, which is usually the result of using too large a broach, 






p q r 

Fig. 93.— A group of abnormal teeth. (Cryer.) 

it must be carefully filed away; otherwise the formation of a pocket 
and finally a perforation of the wall of the root is very apt to 
take place. By alternating the various sized picks and broaches 



180 



DISEASES OF THE DENTAL PULP 



the canal i*> finally cleansed of Its debris and the apical foramen is 
brought within reach. Very delicate apex curettes, the so-called 



i. Pulp canal cleaners. 



apexographei 

ployed foi 

of the apex 1>,\ 



are 



enlargi 



now tMii- 
no- the lumen 
drawing the 
debris into the canal. With 
suitable Kerr files the canal 
may now he enlarged and 
straightened ><> as to assume a 
conical shape which may mate- 
rially assist in placing the gutta- 
percha cone simultaneously 
againsl the wall and the 

apex. 

Consultation of the roent- 
genogram with the diagnostic 

wire in position should l>c Fre- 
quently resorted to. A- stated, 
special attention must he given 

to the upper third of the canal, 

including the foramen. This 

-pace i- the most important 

part of the rool canal in re- 
gard t<» the future health of the 
periapical tissues, which i> 
largelj dependent on the su< - *» 

ml occlusion of this region 
by tin- root-canal filling. 

Chemical Procedures. h< >r the chemica 



Fig. '.»•"). Donaldson pulp 
canal cleaner. 





Rhcin'a picks. 



detritus, but primarily for the 



isintegration of the pulp 
purpose <»f assisting in the opening ol 



NECROSIS AND GANGRENE OF THE DENTAL PULP 181 

obliterated root canals, two specific methods are in vogue, i.e., the alkali 
method, as introduced by Schreier 1 in 1S92, and the acid method, 
as advocated by the late John Callahan 2 in 1893, Schreier's alkali 
method intends to destroy the organic constituents of the calcar- 
eous deposits and, incidentally, to assist in the dissolution of 
necrosed tissue by means of the freshly formed hydroxids of potas- 
sium and sodium derived from an alloy of potassium and sodium 
in the presence of water and thereby rendering the remaining 
inorganic debris more friable and offering less resistance to the 
advancing instruments, while Callahan's sulphuric acid treatment 
produces the opposite effect, i. c, it destroys the inorganic sub- 
stances by dissolution and carbonizes the remaining organic 
material. Both methods have their advocates and they virtually 
accomplish the same purpose. Preference in regard to selecting 
either method is largely a matter of personal equation. However, 
a most important physical property possessed by the alloy and 




XIF XF F M C XC 
Style B 

Fig. 97. — Root canal files. 



which is not possessed by the acid, should be mentioned which 
places the alkali method at a marked advantage over the acid 
treatment. This property manifests itself as a pronounced capil- 
lary affinity of the freshly formed hydroxids for moisture and, 
consequently, the caustic alkali solution penetrates into those 
minute apertures of the root canal in which the acid will not now. 
This fact combined with the solvent action of the alkalies on 
necrosed tissue is of the utmost significance in regard to the open- 
ing of those exceedingly narrow canals which are often too small 
to admit the finest broach. Both methods incidentally destroy 
the offensive odor of putrescence which is always very pronounced 
in a closed root canal and less so in an open one. However, it 
should be clearly understood that the mere absence of foul odors 
is by no means a criterion of sterility. 



1 World's Columbian Dental Congress, 1893. 

2 Proceedings of the Ohio State Dental Society, 1894. 



In: 



DISEASES OF THE DEh TAL I'l LP 



Dental potassium-sodium (kalium-natrium) usually consists of 1 
pari of metallic potassium and 2 parts of metallic sodium mchcd 
together beneath kerosene. It is of a past) consistency ;ui<1 
resembles mercurj in appearance. The alloy i> applied in small 
glass tubes sealed with wax or paraffin for protection. The tube 
musl be hermetically scaled directly after using the alloy to pre- 
vent its decomposition by absorbing moisture from the air. It' 
the sealing is not carried oul in a proper manner the operator will 
find thai the contents of the tube will change to a hard, crystalline 
mass, i. <.. the hydroxids of the two metals. 



i 



Fi« 



98. Tube of sodium-potassium 
alloy. 



- 



A 



n 



I i.. 99. rridio-platinum aerve 
broach. This broach is ool oorroded 
by sodium-potassium : 1 1 1 * • > " and may 
be sterilised by heating i<» redn< 



In using this alloy, a barbed tantalum or an iridi>platinum 
broach is thrusl through the paraffin stopper <>r directly into the 
broken off upper end of the tube. Steel broaches are not to be 
recommended for this work; the alloy disintegrates the metal and, 
as a consequence, the broaches frequently break in the canal. The 
very small quantity of the paste adhering to the broach is worked 
into the pulp debris. Extreme care should be exercised in regard 
to tlic quantity applied to the canal. Onl> the very thin film, 
tree from lumps, which will adhere to the broach is permissible 
to be used with safety. At once a chemical decomposition of the 



NECROSIS AND GANGRENE OF THE DENTAL PULP 183 

moist contents of the root canal takes place manifesting itself by 
heat and a hissing sound with the escape of gas, and, if larger 
particles are used, with little sparks of fire. Potassium-sodium 
alloy in the presence of water is changed at once into their hydroxids 
with the liberation of hydrogen. The hydroxids dissolve in the 
remaining water and form a more or less concentrated caustic alkali 
solution. The putrescent pulp, as stated above, contains water, 
fat, fatty acids, gases and the debris of protein material. The 
rationale of the action of the potassium-sodium alloy on the putres- 
cent pulp debris may be summarized as follows: Fat and fatty 
acids are changed to soluble soaps. The protein substances are 
rendered soluble by the caustic hydroxid solution and the liberated 
hydrogen forces the undissolved debris to the surface of the canal. 
The calcareous deposits in the lumen and upon the walls of the 
canals lose their orderly structure and become friable and thereby 
offer less resistance to the advancing broach. The offensive odor 
of putrescence is almost instantly destroyed. Copious washing 
with water will remove the saponified contents of the canal and on 
drying, its clean, ivory-white walls are visible. The substitution 
of the hydroxids of potassium or sodium for the metallic alloy as 
suggested by Schreiter is not to be recommended; their application 
is difficult and their physical nature does not lend itself to this 
procedure as readily as the alloy from which the above hydroxids 
are obtained in the nascent state during their application. Alco- 
holic solution of sodium ethylate or methylate in various concen- 
trations, i. e., from 2 to 10 per cent has also been recommended 
for the same purpose. 

Sodium dioxid, as suggested by Kirk in 1893, when applied in 
substance to the moist contents of the root canal, is a most service- 
able chemical adjunct for the ready disintegration of the necrosed 
tissue. It is carried into the canal by means of a broach pre- 
viously dipped into chloroform, absolute alcohol, glycerin-alcohol 
mixture (1 to 7), etc. These liquids merely act as indifferent con- 
veyors of the salt, which, if water or a low grade alcohol were 
used as a vehicle, readily decompose the sodium dioxid. The 
decomposition of the latter into nascent oxygen and sodium 
hydroxid exercises a most beneficial and multifarious effect upon 
the necrosed pulp, which in many respects, is equal to that obtained 
from potassium-sodium alloy. 

The sulphuric acid method for opening obstructed root canals 
has found many admirers among the practitioners and it is prob- 
ably more widely employed at present than any other chemical 
procedure. Other acids, such as hydrochloric, nitro-hydrochloric 
and phenol-sulphonic acid have been advocated for this purpose 
during the last twenty-five years. The strength of these various 
acids as used for this specific purpose should be carefully noted as 



184 DISEASES OP THE DENTAL l'i LP 

it varies greatly. Sulphuric ; m - i < 1 is usually employed In approx- 
imately a 50 per cent solution, hydrochloric acid in a 10 to 30 
per cent solution, oitro-hydrochloric acid in a 50 per cenl solution, 
while phenol-sulphonic acid is used in its pure form only. Hie 
therapeutic absurdity of the latter compound has been dealt with 
by the writer on a former occasion 1 and consequently it i> omitted 
in the present discussion. The substitution of phenol-sulphonic 
acid for this or any other purpose in which sulphuric acid is indi- 
cated in dental therapeutics mean- the application of a decidedly 
inferior remedy. 

Nitre-hydrochloric acid (aqua regia) as introduced by G. \Y. 
Weld- in L897, is a very efficient acid for the above purposes. On 
account of its strong caustic properties, extreme care is required 
in handling it. The acid should bo preserved in glass-stoppered 
bottles and kept outside 1 of the operating room, as its fume- are 
most destructive to metallic instruments. The greatest solvent 
power upon dentin is possessed by so-called "reversed" aqua regia, 
/. c, an acid composed of 1 part of hydrochloric acid and -1 parts 
of nitric acid. This acid should be applied upon an iridio-platinum 
or a tantalum broach wound with a few fibers of asbestos to facili- 
tate the mechanical adhesion of the acid. Steel broaches are mosl 
readily destroyed hy the corrosive action of this acid. 

To facilitate the ready application of these acids to the root canals 
it has been suggested to prepare a suitable paste by adding insoluble 
barium sulphate to the acid. The writer cannot advocate such 
mixtures. 

Whatever acid is employed it should be neutralized by sodium 
dioxid conveyed to the canal as described above and not by sodium 
bicarbonate, which is practically of Aery little value for this specific 
purpose. If sodium dioxid is used in connection with an acid it 
should preferably be applied first and then neutralized by the 
acid. The chemical interchanges between the various acids and 
the sodium dioxid may be portrayed by their respective reactions 

a- follow ^: 

1 1 S< h \ s< U + H : 2 

or 

2HC1 \ ■■ <> 2NaCl + II - 

or 

2HNO \ I I ll" 

and 2HC1 | NasOi - 2NaCl + I! 

The freshly formed hydrogen dioxid of the last reaction combines 
with the available hydrochloric acid and forms nascent chlorin: 

II <> • 2H( 1 2&0 - ; - CIi 

1 Prim: Dental ( tamoe, 1912, p. 
I '• ni.il ( losmos, 1897, i 



NECROSIS AND GANGRENE OF THE DENTAL PULP 185 

There seems to be quite a divergency of opinion concerning the 
self-limiting action of these acids upon tooth structure. Fifty per 
cent sulphuric acid solution is self-limiting; a tooth placed in this 
acid will be coated within a day or so on every accessible surface 
with freshly precipitated insoluble calcium sulphate and conse- 
quently no further action occurs. A tooth placed in 10 per cent 
hydrochloric acid, in pure or in 50 per cent nitro-hydrochloric acid 
will be completely dissolved in two or three days; these acids form 
soluble calcium salts. The greatest solvent power is exhibited by 
the " reversed" nitro-hydrochloric acid. The various reactions of 
these acids with one of the constituents of the dentin, calcium 
carbonate, may be depicted as follows: 

H2SO4 + CaC0 3 = CaS0 4 + C0 2 + H 2 
2HC1 + CaC0 3 = CaCl 2 + C0 2 + H 2 
2HNO3 + CaC0 3 = Ca(N0 3 ) + C0 2 + H 2 

From a clinical point of view it may be readily observed that 
the small quantities of either acid pumped into a root canal, when 
used with caution, will do no harm, especially when neutralized by 
sodium dioxid. It is to be understood, however, that no acid 
should be forced through the foramen. This same precaution is 
equally true in regard to the use of potassium-sodium alloy, sodium 
dioxid, etc. 

Incidentally, it should be observed that these various chemical 
agents by their intense caustic effects naturally also act as power- 
ful germicides. Sulphuric acid is the weakest while hydrochloric 
acid, and especially nitro-hydrochloric acid, when neutralized with 
sodium dioxid develops a marked degree of disinfecting action on 
account of the liberated chlorin. Potassium-sodium alloy is a 
most powerful germicidal agent; the freshly formed hydroxids dis- 
solve every vestige of organic material with which they come in 
contact. The intense penetrating power of these hydroxids is of 
material assistance in reaching the minutest ramifications of the 
root canal. As a consequence, quite a few practitioners depend 
exclusively upon the chemical action of potassium-sodium alloy in 
rendering the surface of a root canal sterile. 

Nascent oxygen which is created by the reaction of sodium 
dioxid with any of the acids employed and nascent chlorin obtained 
from the nitro-hydrochloric acid and sodium dioxid reaction as 
depicted above are important additional chemical factors evolved 
in the treatment of the root canal. These bleaching agents will 
materially assist in the preservation of the natural color of the 
tooth. Copious washing of the canal with water after the chemical 
treatment should always be employed to get rid of the products of 
the various reactions and of the debris. The most satisfactory 
results from the utilization of the above discussed chemical pro- 



L86 DISE I SE& OF rill': i>i:\ T LI PULP 

cedures for chemical purposes are obtained by the use of potassium- 
sodium alloy or by t h<* combined application of the alkaline and 
acid methods in logical sequence, i. e., sodium dioxid followed by 
sulphuric or mtro-hydrochloric acid and finally, bj copious washing 
with w ater. 

Therapeutic Procedures. Prior to the introduction of the anti- 
septic era by Lister in L867, ancient and confused delusions of 
miasm, contagion and virus had taken possession of the mind of 
the dental practitioner. He looked for suppuration of the dead 
"nerve" in the afflicted "fang" and if the oozing pus was not 

bonum ei laudabile, he would waste little time in the treatment of 

the offending tooth; he usually removed it. It' a suppurating 
pulp was present in an anterior tooth and he wished to save the 
latter he would drill a small hole in the pulp chamber at a con- 
venient place somewhere near the free margin of the gum to 
give ready vent to the accumulated accretions. Archigenes (about 
130 \.D.> had introduced this operation and devised a small 
trephine for the purpose. This same procedure was advocated 
as a new venture by Hullihen in the middle of the last century. 
Soon after the inauguration of the antiseptic era in surgery, in 
1867 by Lister, dentistry adopted his methods for the treatment 
of root canals in an empiric way by using phenol as advocated by 
Witzel in L873. Since then innumerable other drugs and drug 
compounds have been recommended at various times for this 
purpose among which ma\' be mentioned: Creosote, chloro-phenol, 

camphorated phenol, lysol, cresol, creolin, betanaphthol, salicylic 
acid, hydrogen dioxid, zinc chlorid, mercury' bichlorid, silver nitrate, 
iodin solutions, iodoform, the essential oils, thymol, eugenol, 
eucalyptol, Black's 1 2 3, sodium dioxid, formaldehyd, electro- 
sterilization (ionization), dichloramin-T and many others too num- 
erous to mention. From a clinical point of view the cresol-formalin 
mixture a- introduced by Gysi in L899, and which was widely 
popularized by Buckley in L904, has received greater approval 

than any other medicinal compound recommended for such pur- 
poses. The true criterion of an antiseptic must be based upon 
its bacteriologic efficiency ;i^ tested in clinical cases. The high 
standard of the germicidal activity of Formalin has been frequently 
established l>y rigorous experiments. Clinical data collected in the 
early days of the use of the above mixture pointed to most favor- 
able results. In due time, however, it was observed that while 
"clearing up" of an infected root canal, a- Par a- the ordinary 
diagnostic evidence is concerned ;i^ applied in the average dental 
oilier, i. >., absence of foul odors, occurred much more rapidly by 
the use of this mixture than by employing any of the numerous 
other drugs usually advocated for this purpose, nevertheless, 
secondary manifestations about the periapical tissues were <'t Ere- 



NECROSIS AND GANGRENE OF THE DENTAL PULP 187 

quent occurrence. These disturbances are an indication that the 
supposed sterility of the canal was not obtained at the time of 
its treatment with the cresol-formalin mixture, or that this com- 
pound produces a predisposition of the periapical tissues to future 
infections. To be sure, dental literature is replete with statements 
such as this (referring to the cresol-formalin mixture): "This 
dressing should remain for at least three days, by which time the 
remedy will have sterilized the entire tubular structure of the 
dentin, thus establishing asepsis." As no bacteriologic proof is 
furnished to substantiate this empiric statement it does not carry 
any scientific weight, and it is out of harmony with existing facts. 
Asepsis of the surface of an infected root canal can be temporarily 
established by applying mechanical and chemical measures, but 
complete sterilization of "the entire tubular structure of dentin" 
in a tooth in situ is impossible with the methods at present in 
vogue. 

In regard to the application of powerful antiseptic drugs for the 
treatment of infected root canals, one should always be mindful 
of the following facts: 

1. The agent must be able to develop the highest degree of anti- 
septic power without doing harm to the periapical tissues. 

2. It must maintain its activity for at least twenty-four hours 
when sealed into the root canal. 

"). It must not cause pain. 

4.- It must not discolor the tooth structure. 

Of all the above enumerated drugs only a very few answer 
these requirements. Without entering into a lengthy discussion 
of the merits or demerits of these drugs, it may be stated that, in 
general, the antiseptics of the aromatic series, i. e., phenol and its 
isomers act as caustics when applied in concentrated solution. 
The metallic salts are strong precipitants of albumen; incidentally, 
some of these salts, i. e., mercury bichlorid, silver nitrate, etc., 
permanently discolor the tooth structure. Iodoform, on account of 
its most disagreeable odor and other drawbacks cannot be recom- 
mended for this work and some of the iodin compounds produce 
lasting stains. The essential oils do not possess sufficient antiseptic 
power as compared with other drugs. Formaldehyd in the strength 
in which it is usually applied for root-canal treatment will always 
kill soft tissues when brought in contact therewith either directly 
or in vapor form in the same manner as the ill-fated desensitizing 
paste by its formalin content eventually kills the pulp through 
any thickness of sound dentin. The clinical practitioner should 
be mindful of the following dogmatic axiom: Never seal into a 
root canal a drug which by its passage beyond the apical foramen 
may cause cauterization of the soft tissues. Regarding the action 
of antiseptics as employed in the treatment of infected root canals, 



188 DISEA SE8 OF THE DENTAL PULP 

practitioners are rather prone to depend too much on the specific 
activity of such compounds. There seems to exisl a current con- 
ceptioB thai neglect in regard to the mechanical removal of infected 
pulp debris may be overcome by the application of powerful germi- 
cidal drugs. Tliis inaccurate impressioD is partially the outcome 
of misinterpreting results as observed in test-tube experiments and 
partially it is based upon exaggerated claims made by manufactur- 
ers of certain antiseptic compounds. There can be nothing more 
erroneous than such perverted conception- regarding drug action. 
Neglect of the most painstaking mechanical removal of pulp d€bris 
and chemical cleansing of the canal can never be counter-balanced 
by the future application of drugs. As will be pointed out in 
detail later under " Reinfect ion of Root CanaU," no antiseptic 

treatment now in vogue will permanently sterilize the oner infected 
contents of the dentinal tubuli. 

Chlorin as an Antiseptic. Of all known antiseptics, chlorin, 
freshly prepared, and in the presence of moisture and in a suitable 
concentration, especially in an oily solution, is harmless to the peri- 
apical tissues and it maintains its activity for about twenty-four 
hours when sealed into a root canal. These oily chlorin solutions 
will not cause pain and they do not discolor hut rather bleach 
tooth structure. 

From an historical point of view it i> interesting to observe that 
chlorin in the form of its numerous preparations has had a rather 
checkered career within that group of substances generally referred 
to as disinfectants and antiseptics. In L788 the French chemist 
Berthollet obtained a liquid which exhibited marked bleaching 
and disinfecting properties, and Tennant, of Glasgow, in 1798, 
prepared a more stable compound in the form of chlorinated lime 
for similar purposes. In 1792 the Javelle work-, near Paris, pre- 
pared a liquid bleaching compound for commercial purposes by 
passing chlorin into a potash solution, which since ha- become 

widely known ;i- can de .lavelle or Javelle water. Again, in 1820, 

Labarraque, a French pharmacist, modified this hitter solution by 
substituting sodium carbonate for the potash salt. Tin- solution, 
variously known as Liqueur de Labarraque, as Labarraque's disin- 
fectant fluid, or at present simply as Labarraque's solution, achieved 
great renown at the death of Louis XVIII, "for thanks to the dis- 
infecting and deodorizing value of his liqueur Labarraque was able 
to proceed with the embalming of the royal body, which was so 
profoundly decomposed that no one was able to approach it until 
after the application of the hypochlorite." Dakin.) 

When Semmelweiss, the assistant obstetrician of the Vienna 
Lying-in Hospital, announced, in L846, his epoch-making observa- 
tion concerning the clinical causes of puerperal fever, he selected 
chlorinated lime solution as the agent par excellence for the destruc- 



NECROSIS AND GANGRENE OF THE DENTAL PULP 189 

tion of thatjjoathsome unknown "miasm" which was carried by 
the students, as he observed it, from the dissecting room to his 
wards, and which was the apparent cause of the scourge. Again, 
during the civil war, chlorinated lime solutions were occasionally 
employed to check the frightful destruction of human life by hospi- 
tal gangrene. However, principally on account of the caustic 
effect of the solution employed, together with a faulty technic in 
its application, the compound never obtained the general useful- 
ness which it rightly deserved. With the advent of modern bacteri- 
ology, chlorin has always been a favorite antiseptic in the hands of 
the experimental researcher, and within the province of the hygien- 
ist its application for the purification of drinking water and the 
sterilization of excreta it has achieved most remarkable results, 
and consequently it is at present very largely employed for such 
purposes. 

Repeated attempts have been made in the past by bacteriologists 
to convince clinical surgeons and dentists that chlorin solutions 
are the acme of perfection as far as wound antiseptics are con- 
cerned. As a consequence, various preparations under more or 
less fanciful names have appeared on the market, among which 
Labarraque's solution, Javelle water, electrozone, dental medit- 
rina, radizin, antiformin, eusol, eupad, chlorazene and many others 
are examples. All of these solutions show remarkable activities 
as far as their laboratory tests are concerned; nevertheless in their 
practical application they do not produce the same satisfactory 
results, and hence they have proved disappointing to the clinician. 
It should be borne in mind that most of these preparations are 
strong irritants, and that chlorin solutions are rather labile com- 
pounds; all of the solutions named loose their activity within a 
week or two, hence the disappointing results when commercial 
stock preparations are employed. 

Pharmacology of Dichloramin-T. — The halogens represent the 
most interesting and incidentally the most important group of 
those chemical substances which as a class are referred to as wound 
antiseptics and as general disinfectants. On account of their 
general behavior bromin and rluorin are of less importance for 
such purposes, while iodin and chlorin, because of their high effi- 
ciency and their universal adaptability from a clinical point of 
view, form the most important group among these substances. 

At this moment chlorin is considered "king" among the chemical 
disinfectants; when freshly prepared, in the presence of moisture 
and a suitable temperature, it is the most active disinfectant known. 
From a technical point of view, however, numerous difficulties arise 
in its application which in the past have more or less interfered 
with its universal adaptation. Chlorin as such is ajgas which, 
while it may be readily compressed into a liquid, cannot be employed 



190 D18E ISES OF THE DENTAL PULP 

with ;iii\ degree of satisfaction for wound treatment, as it [a too 
irritating. Suitable solutions prepared From the liquefied gas, a 
process which a1 present is very much simplified, possess necessarily 
all the drawbacks of an aqueous solution. 

The usual solutions which have been most widely employed are 
Labarraque's solution, i. e. s a solution of chlorinated soda and 
Javelle water. These two solution-, however, possess also serious 
drawbacks as far as their clinical application is concerned. They 
readily deteriorate and, incidentally, they macerate the epidermis 
when kept in contact therewith even for a short time only, so as to 
render them practically not only useless but directly dangerous for 
the purpose for which they are intended. 

Dakin, in his studies of the antiseptic properties of the hypo- 
chlorite of soda solution, finally succeeded in preparing a compound 
which is practically neutral and which incidentally contains only 
about n.o per cent of the hypochlorite salt. This solution produces 
virtually no irritating action on the skin and wound surfaces, and 
it is the compound which at present, according to the Carrel- 
Dehelly-Depage technic, is employed in the treatment of wounds. 
The great success obtained with Dakin's solution pests primarily 
upon the fact that a fresh preparation according to specific methods 
is employed, which, while acting deleteriously on the germs, does 
little harm to the tissue cells, as it is a uon-irritating isotonic wound 
antiseptic. The rationale of sterilizing an infected wound surface 
by the Carrel method is based on the following conception: "To 
render an infected wound sterile it is necessary to employ a suitable 
antiseptic in such a manner that the chosen antiseptic comes into 
contact with every portion of the wound, that the antiseptic is 
maintained in a suitable concentration throughout the entire wound, 
and that this constant strength is maintained for a prolonged period. 
II these conditions are fulfilled every wound will >licu its response 
to the treatment by the diminution and disappearance of its micro- 
organisms." Without entering further into a discussion of the 
complicated and time-consuming technic of the above method, it 
suffices to say that the method as well as the solution employed is 

practically Useless for the treatment of infected root canal-. 

Dakin soon realized the clinical drawbacks possessed by the 
various solution of chlorinated soda, and his Further studies led him 
t<> utilize certain synthetic chlorin compounds discovered by 
Chattaway, among which chloramin-T and dichloramin-T are the 
two most important representatives. Chloramin-T, being water- 
soluble, possesses more or less the same disadvantages as any other 
aqueous solution of chlorin. The permanence of such solutions i^ 

limited, and. further. the\ arc \ cr\ quicklj exhausted by 

wound secretions. On the other hand, dichloramin-T, a sub- 
stance soluble in an oih medium, furnishes a veritable reservoir 



NECROSIS AND GANGRENE OF THE DENTAL PULP 191 

for the slow elimination of chlorin which preserves its activity for 
many hours in the presence of wound exudates. 

Dichloramin-T is the abbreviated name of para-tuluene-sulphone- 
dichloramid, CH3C6H4SO2NG2. (The letter T, indicating toluene, 
distinguishes it from similar compounds which have been or may 
be made from benzene, xylene, etc.) 

Graphic Formula 
CH3 CH.3 



\ / 



+ NaCIO = + H-jO 



S02NH2 

Toluene-para-sulphonamid. 


S0 2 NaNCl 
Chloramin-T. 


CH.3 

/\ 
/ \ 

1 


CHs 

/\ 
/ \ 

1 1 


\ / 
SO, Ml 


1 1 
\ / 

S(),X('L 


Toluene-para-sulphonamid. 


Dichloramin-T 



It is a yellowish-white crystalline powder, having a sweetish, 
rather pungent chlorous odor and containing a little over 29 per 
cent of available chlorin. It melts at about 80° C. (176° F.). In 
the solid state, when kept in the dark it is stable. It is practically 
insoluble in water, but is readily soluble in most organic solvents, 
i. e., chloroform, benzene, eucalyptol, etc. It quickly reacts, 
undergoing decomposition with the evolution of nascent chlorin 
when brought into contact with most organic substances, such as 
acids, alcohol and the amins, with hydrogen dioxid, water, etc., 
and certain metals. It should be stored in small amber-colored 
glass-stoppered bottles and protected from heat. 

The strength of dichloramin-T or its solutions may be readily 
estimated by taking an aliquot quantity, i. c, 0.1 gm. of dry dichlo- 
ramin-T or 0.5 gm. of its solution and adding 5 cc of carbon tetra- 
chlorid and an excess of a 10 per cent potassium iodid solution 
and glacial acetic acid. The liberated iodin is titrated with y^ 
sodium thiosulphate solution. Each cubic centimeter of the thio- 
sulphate solution is equal to (3 mg. of dichloramin-T. A strong 
odor of chlorin and incomplete solubility in chloroform are reliable 
signs of decomposition of the salt, while extreme turbidity and the 
formation of crystals in the bottom of the bottle are indications 
of the decomposition of its solution in chlorcosane. 

Solvents for Dichloramin-T.— At the early stages of our experi- 
mental work we prepared the dichloramin-T solution in accordance 



192 DISEASES OF THE DENTAL PULP 

with the original suggestion of Dakin, by using such solvents as 
chlorinated eucalyptol and chlorinated paraffin oil, or ;i mixture of 
both. However, it was observed that these solutions produced 
\;ir\ ing degrees of pain, which we attribute i<» the irritating eff< 
of the solvents. Chlorinated eucalyptol is an unstable body 
which readily decomposes in the presence of dichloramin-T }>y 
absorbing moisture, resulting in the production of volatile acid 
substances. Hence when Dakin announced that he had prepared 
a new solvent for hi- antiseptic which eliminated the above dis- 
advantages of the original solvents, we at once tried out the prepa- 
ration and found it to he fully in accordance with the claim- made 
for it. This new compound is known as " chlorcosane." It is a 
bland, heavy, viscid oil, having a slight yellowish color, and is 
prepared from hard paraffin melting at about 50° C. (\22° F. b; 
replacing a part of its hydrogen by chlorin. Chlorcosane does uol 
contain any "free" chlorin, although it absorbs from }."> to 55 per 
cent of its own weight. The chlorin combines with the carbon of 
the paraffin somewhat in the same manner as chlorin and sodium 
combine to form the ordinary inert sodium chlorid. Chlorcosane, 
by the application of moderate heat, will readily dissolve from s 
to K) per cent of dichloramin-T, which i> more than amply sufficient 
for dental purposes. As the preparation is too cumbersome to be 
attempted by the dentist, chlorcosane, a- well as dichloramin-T is 
best procured through the ordinary trade channels. 

Preparation of Dichloramin-T Solution. Regarding the concen- 
tration of the solution of dichloramin-T for the purpose of treating 
infected rool canals, we have found that a 5 per cent solution of 
the sail in chlorinated paraffin, i. c chlorcosane, answers our 
purpose quite satisfactorily. We have heard an opinion expressed 
to the effect that a 5 per cent solution i^ too irritating when used 
in root-canal work. We cannot subscribe to such assertions; we 
rather believe that the pain resulting from it- application is usually 
due to two causes a spoiled solution and a faulty technic. 

hitions of dichloramin-T preserve their activity for a limited 
time Only; they Usually deteriorate within a month or SO and. there- 
fore, it i- best to prepare a convenient quantity which max- be 
readily used np within a lew weeks. To prepare a dram of the 

solution, which will be amply sufficient for a week'- supply for the 

average dental office, •'! grains of dichloramin-T are placed iii a 

test-tube which must be absolutely clean and free from moisture. 
A few drops of chloroform are added, the tube is shaken and 1 
dram of chlorocosane is now added and the whole is thoroughly 
agitated. The tube is plugged with cotton and placed upright in 
,i mild bath and heated. Within a quarter of an hour complete 
solution usually results. The heat of the -and hath must uever 
be above 194 F 90 C). Overheating must be carefully avoided 



NECROSIS AND GANGRENE OF THE DENTAL PULP 193 

as it will decompose the solution almost immediately. The solu- 
tion is now ready for use; filtering is not necessary. As stated 
above, only dark amber-colored or black bottles should be employed 
as storage vessels; blue glass does not protect the solution against 
the actinic effects of strong light. 

Solution of dichloramin-T must be carefully protected against 
heat, light, water, alcohol and most metals; in fact, most common 
substances have a strong affinity for chlorin, hence the ready 
decomposition of this solution when brought in contact therewith. 
Whenever the solution becomes turbid and forms a deposit of 
crystals in the bottom of the bottle or develops a pronounced odor 
of hypochlorous acid it should be discarded. Fresh solutions, if 
chilled, may temporarily become cloudy, or even precipitate, owing 
to the separation of either dichloramin-T or of solid paraffin. 
Slightly warming the solution quickly restores its usefulness. 




Office-preparation hot tic 



For office purposes it is best to keep the dichloramin-T solution 
in an amber-colored office-preparation bottle with a ground cap 
(Fig. 100). A small glass tube kept in the bottle readily assists in 
obtaining the few drops necessary for each treatment, to be placed 
upon an aseptic glass tray. Under no condition should pliers 
charged with cotton, etc., be introduced into the prepaiation in 
the bottle, and no unused portions of the solution must be returned 
to the stock-bottle. 

The terminology of the substances which are used for the pur- 
pose of combating infection is frequently employed in a very loose 
manner, and without regard to its precise meaning. Hence, 
therefore, it may not be amiss to give as a preamble the definite 
significance of the more important terms as they are used to desig- 
nate the specific nature of their action. It is generally recog- 
nized at present that the breaking down of highly organized bodies 
13 



1111 



DISEASES OF THE DENTAL PULP 



is brought aboul by the activity of minute vegetable organisms 
the bacteria. This process is known as putrefaction, or, under 
certain conditions, as fermentation. The presence ol certain 
bacteria and their products is Instrumental in the production of 
severe physiologic changes resulting in the various \ ital phenomena 
known as infectious diseases. The existence of a condition in 
which bacteria] infection and its sequels are brought about by the 
presence of germs or their products is referred to as sepsis, while 

asepsis implies the entire freedom From such infection. If a pri- 
marily septic condition is changed by some method or means which 
inhibits the growth of t Ik* putrefactive organism, antisepsis is 




"icj. 101. Aseptic medicament tray 



induced. Antiseptics, Therefore, are chemical agents which merely 

inhibit the action and growth of bacteria, while germicides destroy 
the vitality of the infective organisms. Disinfectants also kill the 
bacteria, and incidentally chemically change their poisonous pro- 
ducts to some inert compound. A disinfectant must, therefore, be 
a germicide, while an antiseptic is not necessarily a germicide nor 
;i disinfectant. 

According to Dakin and Dunham, the action of chlorin upon 
bacteria and their products seems to depend upon a process of 
chlorination, i. e. t the amino-acid group of the proteins readily 

ii 

I 
it- < 

NCI 




Ml 



attack all substances containing "active" chlorin in such a way 
that the hydrogen attached to the nitrogen atom is replaced by 

chlorin. The newly Formed compounds contain the NCI group, 

and therefore belong to the class of ehloramin-. 

The chlorin of these newly linked compounds is mMI available, 
and these substances themselves are active germicides. A part oi 



NECROSIS AND GANGRENE OF THE DENTAL PULP 195 

the liberated ehlorin is used by forming inert compounds, that is, 
chlorin unites with carbon to form inert chlorids. Incidentally, 
the liberated chlorin is a strong oxidizing (bleaching) agent which 
is a most beneficial factor in the treatment of pulpless teeth. Chlorin 
further acts as a prompt deodorizing agent, and possesses the 
additional remarkable properties of digesting and removing slough- 
ing necrotic tissue and >jf decomposing toxins. 

Dichloramin-T shares with other chlorin compounds the property 
of being a very active lymphagogue, i. e., the amount of wound 
secretion, especially in the beginning of the treatment, may be 
considerably increased. The writer's attention has been fre- 
quently drawn to this fact by fellow practitioners who have tried 
the compound in treating root canals, and who complained of the 
increased secretions from the canals, which, incidentally, influences 
the granulation of the wound most beneficially. 

The application of the antiseptic principle as utilized in wound 
sterilization depends primarily upon three definite conditions. 

1 . Absolute contact of the antiseptic with the infected organism. 

2. Time during which this contact is maintained. 

3. Sufficient concentration of the antiseptic at the point of 
contact. 

Absolute contact between the antiseptic agent and the substances 
to be acted upon must be rigidly observed, as no antiseptic is 
known to act at a distance. 

Finally, the permissible concentration of an antiseptic depends 
largely upon the tolerance of the tissues with which it is brought 
in contact, and is usually obtained from clinical observation. 
The concentration of the antiseptic solution determines its mass 
action which can be safely employed for tissue sterilization. 

Concerning the relative bactericidal properties of the dichlora- 
min-T solution, Drs. Lee and Furness make the following comment: 

Theoretically, then, this new chlorin compound eliminated at 
the start the chief indication or necessity for the Carrel technic, 
skin irritation. With such a solution it should be possible to present 
to an infection an overwhelming mass of germicide, a 20 per cent 
solution of dichloramin-T being approximately eighty times the 
germicidal mass of 0.48 per cent hypochlorite solution. There is a 
vital necessity, when using germicides in the treatment of infections, 
for the earliest possible application of an overwhelming mass of a 
rapidly acting agent, because infection develops in the tissues at 
the rate of a geometric progression, and not by the slow process of 
addition, and therefore, every minute counts in the end result. 
Dichloramin-T, with a phenol-oil coefficient of about 50, can be 
presented in a larger mass without injury to the tissue cells than 
any other germicide we have used. Instead of having this chlorin 
given up with explosive rapidity and the consequent necessity of 



L96 DISE iSE& OF THE DENTAL l'i LP 

frequent renewals of the solution, it would be slowly diffused into 
the surrounding media, making it unnecessary to renew the solu- 
tion or to dress the wounds more frequently than once in every 
twenty-four hours. Consequently all dead tissue in our particu- 
lar instance, the debris of the gangrenous pulp must be mechanic- 
ally removed. Regarding the factor of time, it must be understood 
that the action of the antiseptic is enormously influenced bj the 
medium in which it i> dispersed, i. e. f a specific solution of one 
antiseptic may kill a given number of bacteria suspended in water 
very rapidly, while this same solution upon bacteria suspended in 
blood serum may he practically insignificant. The stability of an 
antiseptic as an inherent property is also of vital importance, since 
the innumerable changes which it undergoes during its action. 
absorption, etc., are of extremely wide variation. Dr. Dunham 
has very ingeniously depicted the speed of disinfection of a few 
widely used antiseptics in the following chart: 



CD 



(2) 



(3) 









9 lirs. is. 

I I 



Mercuric chlorid: 7 hours. 



A( rillax in: !) hours. 



odium hypochlorite (Dakin's solution) : 1 minutes. 



Q < !hloramin-T: 5 minutes. 



I I >ichloramin-T: | minute. 

In.. 102. Speed of disinfection. A 2 percent solution of r phenol fail' 
sterilise the mixture id twenty-four hours, although the surviving organism* 
only 2 per i<»<><> of those originally present. 2 Mercuric chlorid, 1:1000, accom- 
plished the same degree of disinfection in three hours, and completely Bterilised in 
set en horn ifla\ in, m <!>«■ recently introduced as an antiseptic, 3:1000, killed 

all the bacteria in about nine hours. » Bodhim hypochlorite (Dakin's solution . 
r cent, completely Bterilised in four minutes 5 I !hloramin-T in five minutes. 
• ■ Dichloramin-T, 2 per cenl in oil solution, in less than half s minute when well 
mixed with the septic material. (Dunham 

'ii clui'ii- of Apjrtyihg Dichloramin-T Solution to a Root Canal, - 
Alter the root canal has been suitably prepared bj mechanical and 
chemical means so as to present a conical shaped tube, a freshly 



NECROSIS AND GANGRENE OF THE DENTAL PULP 197 

flamed wire is inserted to the Aery apex and bent so as to form a 
shoulder near the pulpal wall. A roentgen picture is now taken. 
The tooth is again placed under rubber dam, the wire is removed 
and the canal is washed with sterile water and dryed out. Sterile 
paper points assisted by a few drops of aceton, absolute alcohol, 
etc., are serviceable for this purpose. Overheating of the tooth 
must be carefully avoided; however, a fair dryness of the root 
canal must be insisted upon. A suitable paper point is now satur- 
ated with dichloramin-T, carried to the root canal, and with a 
gentle pumping motion an attempt is made to coat the walls of 
the latter, and if possible a droplet is forced into the periapical 
space. The use of the warm air blast is of material assistance in 
getting the oily solution into the finer ramifications of the canal. 
The warm air blast is recommended in this connection solely for 
its mechanical effect in aiding the diffusion of the dichloramin-T 
over the dentin surface, but its use as a means 
for previous desiccation of the canal walls is 
not advisable, for the reason that the natural 
moisture of the tooth structure is necessary to 
the production of nascent chlorin resulting 
from the reaction of the dichloramin-T with 
the moisture of the organic structure of the 
tooth. A fresh point carrying a drop of the 
chlorin solution is now slowly forced into the 
canal to its very end and immediately sealed 
with a suitable retainer. As we have stated 
above, close contact of the antiseptic solution 
with the walls of the root canal, and if possi- Fig. 103. — Absorbent 
ble, with the surface of the involved infected paper polnt - 
area within the periapical tissues, is essential 
to obtain therapeutic results. The first application remains un- 
disturbed for twenty-four hours. At the return of the patient the 
point is removed aseptically and carefully examined. 

A second, a third, or, on rare occasions, a fourth dichloramin-T 
treatment is placed in the dry canal and these applications again 
remain respectively undisturbed for twenty-four hours. The paper 
cone which is removed at the last sitting must show no discolora- 
tion, it must have a distinct odor of chlorin and not of hypochlorous 
acid, and it must be fairly free from absorbed exudates. If possible, 
the treatments should not be left in the canal over twenty-four 
hours, at the end of this time the chlorin compound is completely 
exhausted, and usually a flow of lymph, as referred to above, is 
the sequence. Should the flow of lymph be rather copious, a dry, 
sterile paper cone may be inserted for a day or two under a hermetic 
seal; usually normal conditionsof the periapical tissues will speedily 
return. If at the last treatment the canal is found satisfactorilv 




198 



DISEASES OF THE DENTAL PULP 




1 i... 104. Lower lefl firsl molar 
oarrying a gold Bhell crown. Tender 
on pressure; occasionally Bwelling 
near the apical region with paroxys- 
mal pain at inter \ als. Large rarefied 
area near the apices of the i wo roots. 




I'm., in."). Same t.-oth after treat- 
ment with I >ichloramin-T; four ap- 
plication- .tt intervals of aboul forty- 
eighl hours. 




l-'io. 106. Bacteriologic exami- 
nation of root canals negative; root 
canals rilled. 




Fn.. Ki7. Appearance f >f tooth 
and rarefied area one year after 

t feat Ilient . 




Fig I'i^ First and second left 

lower pre lars;soreon pressure and 

occasionally swelling. 




I'n,. 109. Appearance of teeth 
one week after treatment with three 
applications of dichloramine-T. 
Ja filled. 



I i. 



1 in 



rnnci 




> par alter t real menl . 

■ f infected apical foci. 






NECROSIS AND GANGRENE OF THE DENTAL PULP 199 

clean a microscopic examination in the form of a smear obtained 
from the removed cone is made. If the examination indicates 
sterility, no time should be lost in filling the canal at once. 

Regarding the existing sterility of a primarily infected root 
canal as treated by the above-outlined dichloramin-T method, it 
should be emphasized that rigorous bacteriologic tests were made 
in numerous instances in the routine way by plating out scrapings 
from incubation upon agar plates in bouillon, etc. After exposure 
in an incubator for various lengths of time, usually from forty- 
eight to seventy-two hours, it was observed that bacterial growth 
from the previously infected canals was negative, i. e., no cultures 
were obtained usually after the third, and, in a few cases, after 
the fourth treatment. 



ELECTRO-STERILIZATION OF INFECTED ROOT CANALS. 

History.— The utilization of the electric current for the purpose 
of checking bacterial growth is by no means of recent origin. In 
1883 Colm and Mendelsohn employed a galvanic current experi- 
mentally to study its effect upon bacteria suspended in nutrient 
solution. Apostoli and Laquerriere, in 1890, used a current of 100 
to 150 milliamperes for similar purposes, claiming, however, that 
it is not the current as such but the electrolytic decomposition of 
the nutrient fluid which produces the desired effects. Similar 
results were obtained by Prochowink and Spaeth in the same year. 
In 1891 Versoogen claimed that the bactericidal effect of the cur- 
rent depended on the end products of the electrolytic dissociation 
of a suitable fluid, i. c, acid at the positive pole and alkali at the 
negative pole. The application of this principle for the purpose 
of sterilizing root canals was probably first attempted by Breuer, 
of Vienna, who, as early as 1890, referred to this method in a 
tentative manner. In 1895 Rhein, at the suggestion of Morton, 
employed this procedure in an empiric way with apparent good 
success; he again demonstrated it in 1897, and has referred to it 
at various times ever since. A systematic investigation of this 
procedure was first attempted by Bethel in 1896-1897, and a careful 
perusal of his publications is of the highest interest. However, it 
remained for Zierler to furnish a detailed account of the nature of 
the action of the galvanic current on bacterial infection of root 
canals, and his work, carried out in conjunction with Lehmann 
in 1900, must be regarded as a very complete expose of the pro- 
cedure. Since then quite a host of writers have elaborated on this 
problem, among whom Hoffendahl, Miller, Peter, J. Forbes Webster, 
Frank D. Price, Sturridge and many others should be mentioned. 
The dental profession is particularly to be congratulated on the 



200 DI& OR THE DENTAL l'i LP 

excellent discussion of this procedure as recorded by Sturridge in 
bis commendable work Denial Electro-therapeutics. 

The term ionization as applied to the specific purpose <»t* electro- 
sterilization of root canals is ill chosen. Conization designates 
purely a chemico-physical process, i. >., by the phenomenon of 
electrolysis ions are Induced to migrate. Again, the term ionic 
medication i> employed for Midi procedures. Lewis Jones defines 
it as follows: " Ionic medication is a method of treatment in which 
electric current- are used for their power of setting the constituents 
of a saline solution in orderly motion in a definite direction. It i> 
used for the introduction of drugs into the superficial parts of 
the body through the surface." While the above explanation i- 
compatible with the nature of ionic medication for general medicinal 
purpose, it does not specifically designate the intent for which this 
procedure is applied in the treatment of root canals. The sole 
object of thi> treatment consists in combating infection by the 
most powerful method known, i. /., sterilization. The latter i- 
induced 1>\ a weak electric current through the migration of certain 
ions. Hence the term sterilization by electrolysis, or in short, 
electro-sterilization, as first suggested by Zierler, is eminently suit- 
able for this purpose, and its genera] adaptation is recommended 
by the writer. It has been suggested that the term electro-steril- 
ization merely indicates a substitute for the once famous therapeutic 
procedure known as cataphoresis. This conception is not correct. 

Cataphoresis designates the mechanical movement of suspended 

molecules by means of the electric current. As Such it is a pro 

independent of electrolysis. The rationale of electro-sterilization 

depends on the interaction of two definite processes: I The disso- 
ciation of a suitable chemical compound in a solvent (electrolyte 
into ions, mid (2) the movement of these ions in the direction of 
specific poles within the tissues, brought about by the passage of a 
weak galvanic current. 

Theory of Electrolytic Dissociation. When a solid, liquid or 
enters into solution and Is capable of conducting an electric current . 
according to Arrhenius, the solution undergoes certain changes 
which are grouped under the generic term electrolysis. This latter 

term and the following nomenclature was introduced by the English 

physicist Faraday 179] 1867 and is -till universally employed. 

The suiuTmn itself is know n as the electrolyte, while the dissociated 

products are referred to a- ions. The terminals at which the electric 
current enters or leaves the electrolyte are called electrodes. An 

ion ion = going may be referred to as being the dissociated product 
of ;i chemical decomposition which is capable of conducting an 
electric charge, and which travels in the direction of ,in oppositely 
charged pole. Those ions which arc charged uegatively migrate to 

the anode, i. < ■, the positi\e pole, iind arc known as anions, while 



NECROSIS AND GANGRENE OF THE DENTAL PULP 201 

the positively charged ions migrate to the negative pole, the cathode, 
and are known as cations. Relatively speaking, all metals, alka- 
loids and hydrogen, are positive ions, i. e., cations, while all acids, 
bases, halogens, hydroxyl compounds and oxygen are negative 
ions, i. e., anions. 

As Ostwald has suggested, the cation may be designated by the 
positive sign + or by ', and the anion by the negative sign ~ or 
by'. 

TABLE OF IONS, THEIR ELECTRO-CHEMICAL EQUIVALENTS AND 
RELATIVE VELOCITIES ACCORDING TO LEDUC 

Milligrams per 
Milligrams per milliampere- Relative 

Ions. coulomb. minute. velocities. 

Anions: 

Bromin 0.82 0.049 0.9 

Chlorin 0.307 0.022 1.0 

Hydroxyl 0.18 0.01 1.27 

Iodin 1.31 0.078 1.16 

Salicylic acid 1.4 0.085 

Cations: 

Ammonium 0.06 0.003 1.56 

Calcium 0.206 0.012 0.5 

Cocain 3.0 0.18 0.59 

Gold 0.678 0.04 1.22 

Hydrogen 0.01 0.0006 0.88 

Lithium 0.07 0.004 1.28 

Magnesium 0.115 0.007 0.5 

Mercury 1.03 0.062 0.8 

Potassium 0.4 0.024 1.0 

Quinin 3.9 0.234 0.62 

Radium 1.13 0.066 

Silver 1.1 0.06 0.5 

Sodium 0.23 0.014 1.6 

Strychnin 3.4 0.207 

Sulphur 0.16 0.01 

Zinc 0.33 0.02 0.6 

"An ion may be either a charged atom, as in the case of the silver 
ion, or a charged group of atoms, or molecules. In the case of 
silver nitrate, AgN03, the cation is Ag, and the anion is the mole- 
cule or radicle NO3. The charge of the N0 3 ion is one negative 
unit, and that of the Ag ion is one positive unit, as both the ions 
are monads, or monatomic." (Lewis Jones.) 

A simple solution of salt in water dissociates the salt into electro- 
molecules, the ions, which exist independently of the action of a 
galvanic current. The number of positively and negatively charged 
ions is equi-molecular, i. c, the solution is electrically neutral. 
The ions themselves are suspended in the solution in a chaotic mix- 
ture. The passing of the galvanic current, according to Nernst, 
by its electro-motive force causes a definite movement of the ions 
in an orderly direction to their specific centers of attraction; i. e., 
respectively to the positive and the negative pole. 



•),)•: 



DISEASES OF THE DENTAL I'l LP 



The nature of the movement of ions may be theoretically explained 
according to Nernst, bj the schematic drawing, Fig. 111. 

According to this scheme, it' two zinc electrodes are charged, 
.1 and IK suspended in a zinc chlorid solution, IK from battery C, 
the positive zinc ions, F, are attracted to the negatively charged 
electrode, IK and slowly they move in the direction of this pole. 
The zinc ions discharge their positive charge, therebj releasing the 
negatively charged electrode. The discharged zinc ions are n<>w 
Formed into ordinary metallic zinc. The positively charged elec- 
trode, . I, attract- the negatively charged chlorin ions, E\ the 
latter discharge themselves and dissolve metallic zinc, forming zinc 
chlorid, which at once is again ionized. The resultant ions — /inc and 

C 

h 



;:©:; :j®g: 
:::::;;©^::^©^ 



I'm;, ill. Scheme showing the movement of ions. 



chlorin are dispersed in the solution. Undissociated molecules, 
G, of zinc chlorid present in the solution are not acted upon by the 
current. 'The movement of these ions occurs comparatively slowly 
and may be accurately measured by mean- of an ingenious apparatus 
devised by Kohlrausch. 

The degree of concentration of the -olntion to be ioni'/ed ha- no 

rtl'c< t upon the number of ions produced; the latter depend- upon 
the strength of the current multiplied bj the time for which it is 
applied. In other word-, ionization i- a manifestation oi trans- 
Formed electric enefgj in accordance with Faraday's law. The 
amount of decomposition of an electrolyte i- proportional to the 
amount of electricity which How - through it. 



NECROSIS AND GANGRENE OF THE DENTAL PULP 203 

The process of electro-sterilization of infected root canals con- 
cerns itself primarily with the disinfectant action of the liberated 
ions, and less so with their supposed medicinal qualities. The 
disinfectant action is principally confined to the surface of the 
object treated although a certain depth of penetration is desirable. 
According to Sir Oliver Lodge, chlorin the principal agent depended 
upon in root-canal sterilization develops a velocity of penetration 
amounting to 2.16 mm. per hour for a drop of potential of 1 volt 
per cm. 

The electric current per sc, i. e., at least in the strength suitable 
for root-canal sterilization, does not produce any measurable bac- 
tericidal action. A weak current passed for hours through diluted 
sulphuric acid prior to entering an inoculated Petri dish does not 
inhibit the growth. In the presence of an electrolyte, the current 
acts on the dissociated ions of the latter, and depending upon their 
specific chemical nature, some of the most powerful disinfectants 
may be obtained. It is claimed that certain pure metals as such 
possess slight antiseptic action. This property was first observed 
by the late Professor Miller. According to Behring, this antiseptic 
action is the result of the reaction of certaiir waste products of 
bacteria, primarily lactic acid, with those metals which are capable 
of forming soluble salts, and which diffuse through the medium. 
This antiseptic action of metals must not be confounded with the 
oligodynamic action of certain pure metals in their colloidal state, 
as copper, for instance, on low-type plant cells. Of the pure metals, 
according to the classic experiments made by Thiele and ^Yolf, 
mercury, silver and copper are the only ones which produce poison- 
ous salts in the presence of bacteria, while the other tested metals, 
i. e., platinum, palladium, gold, aluminum, magnesium, zinc, lead, 
tin and iron are wholly devoid of action. In the discussion of 
electro-sterilization of infected root canals, great stress is frequently 
laid upon the specific nature of the metallic electrode placed in 
the root canal as being the factor which produces the desired germi- 
cidal effect. Phein, for instance, insists on using a chemically pure 
zinc electrode in the presence of a sodium chlorid solution, claiming 
that " nascent zinc chlorid" is formed during the process of electro- 
lysis. Other practitioners employ a copper electrode and a weak 
zinc chlorid solution as a substitute for the sodium chlorid solution. 
A zinc electrode employed for electro-sterilization of root canals is 
not only devoid of any germicidal action, but it is also an ill-chosen 
metal for this purpose, because a zinc wire is too brittle to be filed 
fine enough so as to readily enter a minute root canal without 
inviting danger of breaking. 

Ionization of a metallic electrode occurs primarily in the presence 
of a suitable electrolyte, i. e., a solution of a salt of the metal of 
the respective electrode. While theoretically it is true that ions 



204 DJ8E ISE& OF THE DENTAL /'( LP 

of the respective electrode must be produced as a secondary sequence 
of the primary ionization of the electrolyte, practically, in employ- 
ing the l<>\\ amperage tolerated by the human bod} these ions are 
not demonstrable with the ordinary chemical reactions, conse- 
quently, they cannot exercise anj therapeutic effect. A zinc elec- 
trode in the presence of a sodium chlorid solution is not ionized in 
the short space of time and with the low amperage employed in 
the electro-sterilization of root canals, consequently "nascent zinc 
chlorid" ions, which arc believed to have been produced from zinc 
electrodes, are imaginary therapeutic bodies. When a high amper- 
age is employed in experimental work outside of the human body 

sufficient hydrochloric acid is obtained a- a secondary product 
which will act on the zinc pole, forming zinc chlorid. 

The Electric Current and Its Accessories.- The only current suit- 
able for electro-sterilization is the direct current. The alternating 
current as such cannot he used unless it is changed by a transformer. 
This may he accomplished by a chemical "rectifier" or ;t -mall 
motor dynamo. The chemical rectifier without potential equalizer 
has not been found satisfactory by the writer. The source of the 
current may he obtained from the main line, from an accumulator 
or a storage battery, or from a series of cells. If the street current 
IS used, it must he reduced by a rheostat to about 30 to In volts. 
A Dumber of lamps, mounted in series, one lamp of sufficiently 
high voltage, or a wire rheostat, is usually employed for this purpose. 
An ordinary switchboard is le>> suitable, a- there i- always danger 
of shocking the patient through imperfect control. If the street 
current i> used a knife switch should he interposed between the 
rheostat and the current controller. If cells are employed and 
many practitioners and most of the reliable electric supply houses 

regard a cell series a- tin 3afes1 mean- for the purpose in view 

about 18 to 24 Leclanch6wet cells or an equal Dumber of ordinary 
dry cells (Columbia No. 6) are most useful. The silver chlorid 

cell is less Serviceable for our purpose. An ordinary wet or dry 

cell furnishes approximately a little over 1! volts. Recently, com- 
pact types of dry-cell batteries Furnishing a current of very low 
amperage and medium voltage, intended for wireless telegraphy, 
have been placed on the market. These cells arc also useful for 

dental electro-Sterilization. The cells are mounted in series and 

connected to binding-posts. From these posts the current is - 

veyed by means of flexible conducting cord- to a suitable controller. 

The most important feature of a serviceable controller consists in 

the gradual increase or de« rease of the current in very small frac- 
tion- of a millianipere without shocking the patient. A graphite 
or a -eric- wire rheostat, cither plain or as a shunt, is serviceable 
for such pun- l The markings on the current controller Fig. 

L12), be they volts or arbitrary numbers, have little bearing on the 
practical application of the current. 



NECROSIS AND GANGRENE OF THE DENTAL PULP 205 

The current controller, in turn, is connected with a milliampere- 
meter, an instrument for measuring the quantity or strength of 
the current. The milliamperemeter is the instrument of precision 




Fi<;. 112.— The S. S. White current controller. 

which guides the operator in his work, consequently too much 
emphasis cannot be placed upon the importance on obtaining a 
perfect working instrument. 




Fig. 113. — Weston milliamperemeter. 



At this point the writer may be permitted to digress for a moment 
from the subject proper and call to the mind of the reader the funda- 
mental nomenclature governing electrical measurements— as far as 
it is utilized in the following discussion. By the term ampere is 



206 



DISEASES OF THE DENTAL PULP 



meant the unit of strength of a current. A milliampere is 
part of an ampere, expressed as M.A. A volt is the measur 
the unit of pressure of the current, I e., the electric power necessarp 
to drive a current of 1 ampere through a resistance of 1 ohm. It is 
referred to as the electro-motive force and expressed as E.M.F. 
An ohm measures the resistance of a circuit through which a current 
flows and a watt represents the units of power. The current 
strength flowing in a circuit is equal to the pressure divided by the 




1 ,,.. nt. Switchboard for electro-sterilisation. (Mcintosh.) 



resistance. The resistance equals the pressure divided 
strength. The pressure equals the strength multiplied by 
sistance. Therefore, in simple term-: 
Ampere volts * ohms. 

Ohms = volts + amperes. 

= amperes X ohms. 
= volts X amperes. 

lunation as related to the process of 



by the 
the re- 



Volts 
Watts 

[•(•III tin- 



Kt\ c r\]»l 



iterilization, it is obvious that the correct measurement 



electro- 
of the 



NECROSIS AND GANGRENE OF THE DENTAL PULP 207 

amount of current applied to a patient is of the utmost importance, 
as it is the safest means of guiding us during its application. Hence 
the importance of procuring a trustworthy milliamperemeter. 
The best instruments are those constructed after the Deprez- 
d'Arsonval deadbeat (non-trembling) type. The Weston milli- 
amperemeter (Fig. 113) is a most reliable current gauge. The 
face of the latter instruments, suitable for this work, should be 
calibrated in 5 milliamperes, with subdivisions of yV to ^V niilli- 
ampere. To convey the current to the patient, different colored 
flexible cords are employed which terminate in suitable electrodes. 
In connecting up the whole apparatus extreme care must be 
observed in joining equal poles to each other; viz., positive pole 
must be connected to positive pole, and vice versa. To locate the 




Fig. 



-Galvanic battery for electro-sterilization. 



respective poles, the following simple experiment may be employed. 
Moisten a piece of blue litmus paper with water. Place the two 
poles of the battery about 1 inch apart on the wet paper and turn 
on the current. In a few moments a pink spot will develop where 
the positive pole touches the paper. 

The two electrodes are terminals attached for the purpose of 
conveying the current to the patient, and consist of a negative 
electrode which is to be placed on the patient's skin surface, and 
a positive electrode to be introduced into the tooth. The negative 
electrode may be a piece of metallic tubing held firmly in the 
patient's hand, or a sponge electrode fastened to his wrist, or one 
of various modifications thereof. The size of the negative hand 
electrode is important ; it should present at least five square inches 



208 



mrfa 



DISB \J3ES OP Till-: DENTAL Pi l.r 



pface ;in;1 ' which are to be brought into contact with the patient. 
A large surface of the negative electrode reduces the resistance, and 
consequently the tingling sensation or even blistering caused by 
the hen of a small electrode is avoided. The writer prefers the 




l n; 



Metal oegath <• band electrode. 



plam tube hand electrode, as it avoids the cumbersome wetting 
with salt water, loss of time in adjusting it, etc. It is immaterial 
in which hand the electrode is held. Rings, bracelets, wrist- 
watches, etc., must be removed, others ise blistering of the patient's 
skin l>\ mere contact may occur. To place the negative electrode 



NECROSIS AND GANGRENE OF THE DENTAL PULP 209 

upon the patient's cheek, lip or gum surface by means of a clamp 
or spring, as recommended by some operators, is to be avoided, for 
the reason that severe burns may result. It has been stated that 
this blistering results from the formation of caustic sodium hydroxid 




Fig. 117. — Sponge hand electrode. 

near the negative pole. The blistering is the result of imperfect 
contact between the skin and the metal electrode, thereby increas- 
ing the resistance of a small area to such an extent as to produce 
high heat, i. e., an electric burn. The positive electrode to be 
introduced into the tooth consists of a piece of iridio-platinum wire 
No. 20 gauge, about one inch long and tapered to a delicate point. 




Fig. 118. — Sponge wrist electrode. 

The iridio-platinum alloy possesses the necessary flexibility, which 
is lacking in pure platinum. The point itself is ground blunt so 
as to avoid being caught when introduced into tortuous canals. 
Various sizes of these points may be kept on hand. No other 
14 



210 



DISEASES OF THE DEA TAL I'l LP 



metal should be employed for such purposes. To substitute the 
iridio-platinum point by zinc, copper, or any other metal with the 
view of aiding it s therapeutic effects is not only useless bul it 
markedly interfere- with the action of electrolysis in the rela- 
tively small area of a root canal, or the re-ultant ions may discolor 
the tooth. A long-handle electrode bolder, Insulated with hard 
rubber i^ essential to suitably unite the electrode w ith the conduct- 
ing cord. r ldie holders may he of various types so as to give ready 
access to all parts of the oral cavity. Prom the foregoing descrip- 



1 19. Long-handle electrode with 

iii(lio-|.l.it iiiiiin point. 



to. I 20. Insulated electrode 
holder. 



tion of the source of the current, its control and its mode of appli- 
cation, it may be observed that essentially it is a duplicate of the 
armamentarium a- applied in producing cataphoresis. Any appa- 
ratus, therefore, thai is or ha- been used f<>r inducing cataphoresis 
ma\ he equally successfully employed for tin- electro-sterilization 
of root canals. 

Electro-sterilization Equation. In the various communications 
treating on root sterilization by electrolysis the very important 
questions concerning the time during which the current i- applied, 
the number of milliampe'res employed and bacteriologic tests <>f the 



NECROSIS AND GANGRENE OF THE DENTAL PULP 211 

resultant sterility are usually vaguely treated. When sterility of 
a primarily infected root canal is spoken of in the present light of 
bacteriologic knowledge, the truth of this assertion has to be proved 
by rigorous tests, otherwise the term sterility loses its significance. 
These tests are readily made by obtaining cultures at stated inter- 
vals from the canal under treatment until complete negative results 
of growth are obtained. Regarding the bacteriologic tests as 
applied to electro-sterilization, the author proceeded as follows: 
Cultures of the infected root canal were made before treatment was 
instituted, and then every five minutes thereafter for a given period 
of time, usually twenty minutes. The infected agar plates were 
incubated in the routine manner (see below). Incidentally, the 
time of applying the current, and also its strength, were carefully 
noted. By comparing the results obtained, a definite relationship 
between the strength of the current, the time of application and 
the resultant sterility could be established. Zierler deserves credit 
for having first noted the inter-relationship of these factors, and 
he had suggested the use of a numerical constant which furnishes 
a working basis for its clinical application. This constant is 30. 
By multiplying the number of milliamperes employed by the time 
in minutes used in the process of obtaining a sterile root canal, 
invariable a number was obtained which closely hovered about the 
figure 30; or, reversely, by dividing the constant 30 by the number 
of milliamperes employed, a quotient is obtained which gives the 
time in minutes during which the current must be applied. Appar- 
ently, a given infected surface area requires for its sterilization, a 
specific amount of migrating ions; at least this assertion can be 
verified as far as the germicidal action of ionized chlorin is con- 
cerned in the sterilization of infected root canals. Hence the 
numerical constant 30 may be looked upon as expressing in units 
the surface area of an average root canal. In the author's experi- 
mental work and in clinical practice he has based his observations 
upon the above principle, and has collected sufficient data as proofs 
that the appended electro-sterilization equation, as this formula 
has been termed, is a reliable guide for the application of these 

procedures in the treatment of infected root canals: 1vr . =T, 

the 30 representing the numerical constant, M.A. the number of 
milliamperes, and T the time in minutes. 

The tables on page 212, selected from experimental records, will 
substantiate these claims. 

If the three constants which show sterility = 102| are added, 
and the total divided by the number of patients, the average con- 
stant will be 34, which in round figures may be reduced to 30. 
Various attempts were made to materially lower this constant, 
but so far (as regards sodium chlorid solution) have not been 
successful. 



2 DI8E i $E& OF I in: hi-. \ TAL n l.i' 

i \i:i i. \. I I I < I R0-S1 i i;ii 1/ kTJON 01 i ill B i\ tin: 1101 i Hfl 

01 PATIENTS. 



Patient. 


Milliam- 


Electrolyte. 


.". tmii 


111 mill 


1.". mm 


( lonstanl 


No. 1 


0.5 


l per cent 
Bod. ohl. 














.solution 


+ 


+ 


+ 





No. 2 . ... 


L' 5 


" 


+ 


+ 







No. 3 ... 


3.0 


" 


+ 





<> 




\... 1 . 


3 5 


.. 


+ 








.;:, 


No. ■". 


1.5 




+ 


+ 


+ 






Growth -t ■■ No growth <•. The inoculated :^;ir plates arc incubated at twenty- 
four hours at in ( . 

TABLE B. ELECTRO-STERILIZATION 01 EXTRACTED Tl.llll BAYING 
G INGRENOUS ROOT < \\ \l.-. 



Teeth. 



Milliam- 
peres. 



Electrolyte. 



5 min. 10 min. 15 min. 25 mill Constant, 



No 



(i 5 



No. 2 . . 


i ii 


No. 3 . . 


2.0 


No. I . . 


:; ii 


. . . 


5.0 



1 per cent 

B0d. ••hi. 

solution 



+ 


+ 


+ 


+ 


+ 








<> 









+ 










<> 


30 







II 


_'."» 



Growth I . No growth 0. The inoculated a<_ r ar plates are incubated for twenty- 
four hours al it) C. Total constants: 1 10 : l = 27$ average constant. 

TABLE C ELECTRO-STERILIZATION OF PLATED MIXED I I ill RES 
OBTAINED FROM GANGRENOUS ROOT-CANALS l\ \<.u;. 



Plate. 



^\ l ,!. l r 1 ,', 11 '" Electrolyte 5 min. in mm. 15 min 



No. l 


l .0 


1 per <-<'iit 








Bod. chl. 






solution 


■ . 


2 ii 


" 


I 


3.0 


•• 


No. I 


l ii 





+ 

ii 30 

ii 30 

ii m 



< Irowth | . No g ro wt h 0. The inoculated agar plates contain l per cent sodium 
chlorid and are incubated for twenty-four hours a! i" C. rotal constants: l( 
■ onstant. 



+ 


+ 


+ 


+ 


+ 


II 








The above experimental work furnishes sufficient proof, and this 
Pad is borne out in clinical practice, that sterility of the walls of 
an infected runt canal mas be obtained 1»\ electro-sterilization. 



NECROSIS AND GANGRENE OF THE DENTAL PULP 213 



It should be borne in mind, however, that this particular type of 
sterilization means sterility of the tcalls of the root canals only and 
not of the entire tooth root. To prove the correctness of this 
statement, which on its very face is self-evident, tooth roots Nos. 
2, 3 and 4 of the experiments recorded in Table 
C were cut into coarse shavings, plated on agar, 
and placed in the incubator. In twenty-four 
hours all three plates showed luxuriant growth. 
Here will be emphasized again what has been 
stated in the past at frequent intervals: Com- 
plete sterilization of an infected root in situ is 
impossible by any of the present known methods; 
complete sterilization of the surface of an infected 
root canal is possible by electro-sterilization as 
outlined above. 

Clinical Application of Electro-sterilization.— To 
convey to the reader a practical working knowl- 
edge of the clinical application of the principles 
of electro-sterilization, it is probably best to de- 
scribe the actual modus operandi in detail as em- 
ployed in a typical case. The patient being seated 
in a chair is covered by a rubber apron suffi- 
ciently large to reach over the chair arms, so as to 
protecthim from accidental shock by " grounding" 
the current. The root canal of the tooth to be 
treated must be mechanically cleansed of its 
debris, and if necessary enlarged so as to give free 
access to the wire electrode. Before starting the 
ionizing process it is best to assure oneself of the 
correct working of the current by bringing the 
two poles together for a moment; the moving of 
the needle of the milliamperemeter in the right 
direction acts as an indicator that the apparatus 
is in working order. The rubber dam having been 
adjusted, the root canal is now flooded with a 1 
per cent saline solution— an S.S.W. minim syringe 
is useful for such purpose. The patient takes a 
firm hold of the negative electrode with his hand, 
which must not carry rings, bracelets, etc. Before 
introducing the freshly flamed positive pole into 
the canal the operator should see to it that the 
knife switch is open, and that the controller is 
set at zero. If the wire electrode fits the canal too loosely, a 
few fibers of cotton moistened with salt water are wrapped about 
it. The needle is introduced as near to the apex as possible, 
and the knife switch is closed. The controller is now very slowly 




Fig. 121.— Minim 
syringe for applying 
saline solution. 



21 1 



DISEASES OF THE DENTAL PULP 



turned on, and the patient is told to at once raise his hand when 
he feels the slightest sensation. The moving needle of the milli- 
ampe'remeter will indicate to the operator that tin* current is 
Bowing in the right direction. When the patient raises his hand the 
controller is turned verj slightly back, left at this point for about 
half a minute, and again very slowly turned forward until the 
patient again responds, or until the point of tolerance is established. 
This point the writer has termed the "irritation point." A glance 
at the milliamperemeter conveys to the operator the number of 
milliamperes employed. The operator now retails to his mind 
the numerical constant 30, and quickly calculates the time of his 
particular < ase of electro-sterilization by <li\ iding 30 by the number 
of milliamperes employed. The resultant quotient gives the time 
in minutes for which the current must be applied. Example: If 
the patient's irritation point is 2.5 M.A., twelve minutes by the 




I [q. 122. Lower righl second 
premolar. Hoot canal is imperfectly 
filled. A rarefied area is visible aboul 
the apical end. < 'ontinuoue gnawing 
pain on pressure. 




In,. 123 Same tooth a- ii 
122. Hoot canal treated by electro- 
sterilisation; root canal filled. Former 
trouble has completely subsided. 
Roentgenogram taken a year later; 
tool h in perfect condition. 



watch are required for the sterilization of this particular root 
canal. If the resultant quotient is a fraction the writer recom- 
mends that the next higher unit be substituted as the indicator 
of the time. Bach root canal of a multi-rooted tooth is preferable 
treated separately. It' a clamp electrode holder is employed to 
clasp the two or three wires inserted into the multi-rooted tooth 
care should be exercised to prevent short-circuiting. To avoid 
polarization of the positive electrode, i. <., covering by a film <>t' 
nascent gases which materially interferes with the flow of the 

current, the needle should he removed at li\ c-niinute intervals turn 

oil* current previously!) and wiped oil'. During the process of 
electro-sterilization a drop of -alt water should he added about 
everj minute to make up for loss of evaporation, (arc must he 
exercised to prevent short-circuiting of the current by allowing 
salt water to seep under the rubber dam and thus transfer the cur- 



NECROSIS AND GANGRENE OF THE DENTAL PULP 215 

rent to the gum tissue. After finishing the operation the controller 
is slowly turned to zero, the knife switch is opened, and the elec- 
trode removed from the tooth. Never remove the electrode with- 
out having first cut off the current, otherwise the patient receives 
a disagreeable shock or a flash of light passing in the eyes. On 
passing a few fibers of cotton or a paper cone in the root canal, a 
pronounced odor of chlorin should be perceptible. A wisp of cotton 
or a cone wet with salt water is placed into the root canal, and the 
latter is closed with gutta-percha stopping. The treatment is to 
be repeated within twenty-four hours, and if necessary again on 
the third day, and the canal is immediately filled after the last 
treatment. A root canal should never be filled immediately after 
the initial treatment; an interval of at least twenty-four hours 
should be allowed before doing so. Migrating ions do not develop 
their maximum degree of therapeutic efficiency within the short 





Fig. 124.— Upper left first pre- Fig. 125. — Same tooth as in Fig. 
molar. Chronic pericementitis with 124. Root canal treated by electro- 
obscured area about the foramen; sterilization; root canal filled. Roent- 
root canal filled with pus. Con- genogram seven months later; no 
tinuous pain for over a week. further trouble observed. 

period of time during which the current is applied. It requires 
practically twenty-four hours to produce their full activity within 
the region of a root canal and its surroundings. The clinical indi- 
cations of complete sterility are definite odor of chlorin and a 
clean paper or cotton cone after twenty-four hours' insertion. In 
doubtful cases sterility should be verified by a bacteriologic test. 
If a metal filling is present in the tooth under treatment it should 
be removed, because if touched by the electrode after the current 
is turned on it may be short-circuited through the filling, and the 
patient will receive a shock. Moreover, the action of the chlorin 
ions upon the metals of the filling materials results in the formation 
of metallic chlorids, which infiltrate the dentin structure, producing 
discoloration. This is particularly true in the case of gold chlorid 
thus formed, which by secondary decomposition stains the tooth 
structure a deep purple tint. 

When the products of pulp decomposition pass beyond the 



216 DISE VSES OF THE DENTAL n LP 

foramen of ;i tooth, localized pathologic disturbances of the peri- 
cementum arise, which usually lead to the Formation of an abscess. 
Without entering into the further discussion of the pathology of 
the disturbances a1 this moment, lei us assume thai the disturb- 
ances an- eradicated by establishing drainage along the lines of 
leasl resistance. If the drainage takes place through the rool 
canal this condition is spoken of, although wrongly, as a blind 
abscess, while if the drainage occurs through an artificially estab- 
lished canal through the bone and gum tissue a fistula results. 
Acute types of the enumerated disturbances yield readily to electro- 
sterilization, provided the sail solution and the positive electrode 

reach the seat of the infection. For the t reatineiit of an abscess 

draining through the root canal the positive electrode is thrusl 

through the foramen into the abscess cavity; the treatment of an 

abscess with a fistula requires a somewhat modified application. 1 n 
the latter case complete communication between the root canal 
and the mouth of the fistula musl be firsl established by forcing 

warm salt water through the canal. The root canal is now trcat< d 
as outlined above; the fistula itself requires a separate application 
of the procedure. The positive electrode is passed into the fistula, 
entering at its outlet and carried along the fistulous tract until the 
root is felt, while the negative pole, consisting of a piece of copper 
wire surrounded by salt water, is placed in the root canal. The 
sterilization equation for this treatment is the same as already 
outlined. Usually the patient requires a lower milliamperage for 
such work. All types of chronic abscesses will yield to this method 
of treatment, provided the necrotic area involved is very small. 

and that the seat of disturbance is reached by the electrode and by 
the sail water. 

SILVER NITRITE IN THE STERILIZATION OF INFECTED 
ROOT CANALS. 

Silver nitrate a- a means of sterilizing infected root canals has 
been recommended at various times during the lasl decades. A 
mosl excellent discussion appeared by Bethel, 1 in 1898, and ever 
since, sporatically, it has been advocated anew. The solutions 
employed for this purpose vary greatly in regard to their strength 
and relative to the nature of the reducing agents employed. The 

impregnation of the walls of a root canal or of carious defects with 

silver nitrate unquestionably permanently inhibits further microbal 

infection. 'Hie process may he explained as follows; The favor- 
able action of argentic nitrate on the course of caries is obtained 
1>\ the insoluble combinations which it forms with the organic 

1 Ohio Dental Journal. 1896, N 



NECROSIS AND GANGRENE OF THE DENTAL PULP 217 

tooth substance, and thus withdrawing the nourishment from 
the bacteria. We may assume that the chemical process con- 
sists in the coagulation of the albumin by the liberated nitric acid 
and the formation of insoluble silver albuminate and of silver oxid. 
Furthermore, since the animal tissues always contain sodium 
chlorid, a further chemical change occurs, in which the nitric acid 
ion of the argentic nitrate combines with the sodium and the 
chlorin combines with the silver to form the insoluble silver chlorid : 

AgN0 3 + NaCl = AgCl + NaN0 3 

Miller has proved, however, that this newly formed insoluble 
silver chlorid does not resist the action of acids in any marked 
degree, but that it is the solid mass of precipitated black silver- 
albumin chlorid which acts principally as the resisting force. 
This explanation corresponds with clinical observations. If silver 
nitrate is placed into a cavity or upon tooth structure and is imme- 
diately covered by a protective layer of gutta-percha or cement its 
action is largely nullified; only a lemon-yellow stain— xanthopro- 
tein— results. On exposure to light, the yellow color changes to 
a jet-black stain which now is immune to caries. Hence the sig- 
nificance of Black's dogmatic postulate: "Expose the tooth sur- 
face treated with silver nitrate to sunlight for ten minutes until a 
full black is obtained." The many offered substitutes for silver 
nitrate, i. e., silver lactate and citrate, or the colloidal silver and 
the organic silver compounds are of little practical use for this 
purpose. 

Shanasy, in 1910, advocated formaldehyd and caustic potash as 
reducing agents while Howe 1 employs an ammoniated silver nitrate 
solution reduced by formaldehyd, and Rickert 2 employs a moist 
silver oxid precipitated by the hydroxid of potassium or sodium. 
Again, other practitioners have used essential oils, such as oil of 
clove, eugenol, etc., for the same purpose. Howe employs the 
following procedure : 

"Two solutions are required. 

"Solution 1.— This consists of a saturated solution of silver nitrate 
in water to which is added little by little strong ammonia. As 
the ammonia is added a dark precipitate of silver oxid is thrown 
down. This is soluble in an excess of ammonia, therefore continue 
adding the ammonia until the solution becomes clear. 

"Solution 2.— This consists of a 25 per cent solution of formalin 
in water. 

"These two solutions must be kept in separate dark-colored 
bottles, with glass stoppers, and should be kept away from the light 

1 Dental Cosmos, 1917, p. 891. 

2 Journal of the National Dental Association, 1919, p. 930. 



218 



DISEASES OF THE DEh T W. PULP 



as much as possible. They \\ ork better it' they are freshly prepared, 

t)in are -till good after a considerable time, it' kept as recommended. 

"The principle employed is that of reducing the silver from its 

Solution. Metallic silver is thrown down in a Very finely divided 

state. It is deposited upon the sides of a clean test-tube as a 

mirror. The principle is used in photography and iii staining 

methods in histology. The action in the tooth is the same. A 
finely divided deposit of silver in its metallic form occurs wherever 





Fio, 127 

Fios. 126 and 127. Teeth treated with Bilver nitrate by tin- Howe method. The 
health} tissue i- nol penetrated by the silver solution, Inn tin- infected structure i-. 
I Howe.) 

the liquid penetrates. By successive applications a very appreci- 
able thickness of deposit occurs. This may be burnished and made 
to take on the luster of the metal. The reaction in this method i> 
as follows: 

2AgNOj r L'N'H.ini - A -I) : J\l(.\" II <> 
A&0 } CHtO + 2Ag + II' IOOH 

"Formic acid acts readily as a reducing agent . taking away 03 
and forming carbonic acid, IM'(). ; . which decomposes easily into 
carbon dioxid and water. We have then practically metallic 
silver and nothing else. The reaction sterilizes, as we have ascer- 
tained l».\ repeated examination and at the same time leaves this 
heavy deposit of metallic silver in a tine state of subdivision, \\ hich 
penetrates all affected dentin hut doe-- not penetrate the sound 

t issue of the teeth. 

"The method of procedure is very simple. Such slight changes 

;i- are needed to make it adaptable to different localities in the 

mouth can readily he solved by the ingenuity of the operator. 

"It i- better to apply the rubber dam or to protect the ti^>ue^ in 
some way. Any applicator will answer the purpose tor conveying 
the liquids to the cavity. Broaches wrapped with cotton will 



NECROSIS AND GANGRENE OF THE DENTAL PULP 219 

serve the purpose or glass tubing drawn out to a capillary end may 
be used. These Ave prepare by heating a piece of small-bore glass 





Fl(i - l28 Fig. L29 Fig. 130 

Figs. 128, 129 and 130.— Illustrating the penetration of the silver solution to the 

very end of the roots, even when the broach is unable to reach it. (Howe.) 

tubing iii the middle and drawing it out to a capillary. With a 
file this is then broken in the center. One tube we keep for the 
ammoniacal silver solution and the other 'for the formalin. If the 




Fig. 131 





Fig. 132 



Fig, 133 

Figs. 131, 132 and 133.— Localized areas of dentin which have become hyaline 
are not stained by the silver nitrate solution; the tubules are absolutely sealed. 
(Howe.) 

solutions are of sufficient depth in the stock bottles the liquid will 
collect in the capillary end of the tubes, or it can be drawn up into 



220 DISEASES OF THE DEh TAL n LP 

the tubes by suction. The lluid can l>e retained and controlled 
by placing the finger over the large end of the tube. Tubes with 
curved cuds arc used For the upper teeth. 

"A tube of Solution I is taken, the capillary portion filled, the 
finger placed over the end and this is conveyed to the cavity. By 
momentarily raising the finger a small drop of the silver solution 

is allowed to flow into the tooth. A -mall drop of Solution 2 i- now 
(lowed in, the solution darken-, silver LS reduced and i- deposited 
upon the surface. After a few moment- absorb this solution and 

repeat the process in order that more silver may he reduced and 

deposited. 

"It i- well to protect the hands with rubber gloves or to wear 
finger-cots. Throughout the treatment the silver that i- deposited 

in the dentin is black. It is no longer silver nitrate; it i- no longer 
formaldehyd; it is simply metallic silver that i- deposited, with 
the formation of weak formic acid, which latter is readily converted 
into carbon dioxid and water. Sound dentinal tissue doe- not 
discolor, hut any carious tissue appears jet black. An\ tooth. 
even an anterior one, can he protected from the discoloring effects 
of these solutions by a coating of adhesive wax. By neatly cutting 
away the wax the treatment can then he applied at the point where 

it i- Indicated." 

Kickert has modified Howe'- method and he employes the 
following procedure: "The silver solution u^\ for rapid redui taon 
is made up a- follows: Silver oxid is precipitated from a silver 
nitrate solution by KOI I or NaOH. This is carefully washed to 
remove all impurities and kept moist in a small amber-colored bottle. 
In this condition reduction is so slight that we have kept it for a 
long time without much change. If a small amount is insoluble in 

exec-- of ammonia there has been too much reduction and the 

silver oxid should he Freshly prepared. This is our stock solution 

made from silver nitrate, because it is free from nitric a< id and other 

impurities. 

"Now when we desire rapid reduction, as in a pulp-capping or 
root reaction, the silver oxid is added to a drop or two of ammonium 
hydroxid to the point of saturation. In this state 'he ammonia* a! 
solution is easily reduced. The (nix 1 with which reduction takes 
place with this solution is so marked that even burnishing with a 

warm glass rod i- sufficient to reduce it to the lustTOUS metallic 

silver. There i- one precaution that mu-t l»c mentioned here. 

That i-, that after a few hour-, fulminate of silver may be formed 

from the anunoniacal solution, which i- very explosive. I have 
taken old solutions of both Dr. 1 1 owe"- and m\ formula- and incom- 
pletely reduced the same in teeth or on blotting paper, both pro- 
ducing explosions on being touched with a hot platinum win- or 

I>\ use of the electric current. SerioUS accident- arc possible from 



NECROSIS AND GANGRENE OF THE DENTAL PULP 221 

even wet solutions. Only very small amounts of ammoniacal 
solutions should be made and the unused portion discarded imme- 
diately after treatment. After complete reduction there is no 
danger and only old ammoniacal solutions, especially after drying, 
are to be avoided." 

The application of silver nitrate for the purpose of root-canal 
sterilization possess certain advantages, which, however, are com- 
pletely nullified by its numerous disadvantages. It is true, as we 
have stated, that silver nitrate is the best sterilizing medium of 
such infected dentin which for some reason cannot be excavated. 
However, if the employed ammoniacal solution passes beyond the 
foramen in the treatment of infected root canals, it is almost sure 
to cause severe pericementitis. A simple concentrated solution in 
distilled water is less irritating; it, however, as well as the ammoni- 
acal solution will at once produce a solid precipitate upon the sur- 
face of the soft tissues which prevents its further penetration into 
the tissues and, consequently, deep infections of the tissue are not 
reached. Only a very diluted solution, i. c, about 2 per cent will 
allow a fair penetration into deeper structures. The greatest objec- 
tion to the use of concentrated silver solution consists in the perma- 
nent deep black discoloration of the root which is so very pronounced 
in cases of anterior teeth that often it may be visible through a 
thin alveolar process and anemic gum tissue. A bluish-black 
colored outline of the root upon the gum surface is the unsightly 
result. 1 

1 For a more detailed discussion, the reader is referred to Prinz: Materia Medica 
and Therapeutics, 5th ed., St. Louis, Mo. 



CHAPTER XVIII. 

REINFECTION OF ROOT CANALS. 

[f a primarily infected root canal which has been treated by 
approved methods and thereby rendered sterile upon it- surface 
is sealed with cement and with an antiseptic dressing left in situ 
for some weeks, it will be found that at a subsequent bacteriologic 
examination the canal again is, in most instances, reinfected with 
precisely the same organisms which caused the original infection. 
These reinfections apparently occur in chronologic sequence. 
Mayrhofer lias shown thai at the end of the first week after com- 
plete surface sterilization about 75 per cent of the treated canals 
proved to be sterile; at the end of the second week about half and 
at the end of the eighth week only 10 per cent remained sterile. 

The nature of the employed antiseptic, i. e., in this particular 
instance formo-cresol, seems to make very little difference, although 
we have observed that electro-sterilization or the application of 
dichloramin-T slightly lengthens the period of temporary sterility. 
However, one important fact stands* out preeminently: .in in<-ii>i- 
ently infected root canal cannot he sterilized permanently by fin anti- 
septic methods of treatment now in vogue. To completely sterilize 
an infected tooth root, basing our conception upon our present 
knowledge of antiseptic action, means to remove the tooth bodily 
and thoroughly boil it. Irrespective of this established fact, 
contrary statements are commonly found in current literature. 
Infectious material may he obtained at almost any time from a 
so-called sterilized tooth root and when placed in a nutrient medium 
will always show a luxuriant growth of pathogenic microorganisms. 
Complete sterilization of infected tissues can only be attained bj 
the harmonious cooperation of three important factors: Absolute 

contact, time during which this contact is maintained, and suffi- 
cient concentration of the employed antiseptic. A break in the 
circuit always indicates failure. The complicated system of dentinal 
tubules which traverses the dentin from the pulp canal toward the 
periphery offer- ready hiding places to the infective organisms and 
,-i^ the interior of the dentinal tubules cannot be reached l>y mere 
surface application of an antiseptic, the destruction of these deep- 
seated bacteria will always bea failure. These verj conceptions 
are clear!} set F orth b} the late W. I>. Miller as earl} a- 1890 when 
lie Mated that: " We must, in Hie first place, reconcile ourseh es t<> 



REINFECTION OF ROOT CANALS 223 

the fact that a complete sterilization of a suspected tooth with the 
conservation of the periosteum is absolutely out of the question." 

The most momentous question arises at once: How does this 
reinfection occur? Four possible modes suggest themselves. The 
reinfection may start by gaining entrance into the filled canal from 
the pulp chamber; it may occur ma the circulation; it may pass 
along the pericementum from the gingival margin, or it may take 
place from organisms left in the canal or in the dentinal tubules. 
The first route is rather difficult to imagine, especially when the 
root canal filling, which is naturally more perfect near the pulp 
chamber, is covered b\ a layer of oxychlorid cement. This cement 
offers an effective barrier against reinfection. Secondary inva- 
sions from areas about the empty apical region of pulpless teeth 
through hematogenous systemic infection do occur in the same 
manner as, reversely, they are observed in other organs of the body 
from focal infections. Reinfections from a marginal pericemen- 
titis which by continuity spreads toward the apex does also occur. 
Such cases are comparatively rare and are easily diagnosed. 

The greatest majority of reinfections may be explained upon 
the basis that the infective organisms have remained undisturbed 
within the body of the tooth structure and they have escaped 
destruction during the supposed process of sterilization. It should 
be remembered that one solitary organism left unharmed may be 
responsible for the entire reinfection as the power of self-propagation 
of bacteria is enormous. As the late Miller has estimated, one single 
cell may produce 16,000,000 offsprings within twenty-four hours. 
The unharmed organisms must, of necessity, have found a safe 
harbor within the complex system of dentinal tubules which traverse 
the dentin everywhere or in the finer deltoid canals branching off 
from the main root canal near the foramen. By an ingenious 
method of counting Roemer succeeded in estimating the number of 
these tubules. Near the amelo-dentinal junction he counted some 
14,700 tubuli within the area of a square millimeter. The number 
of these tubules progressively increases in the direction of the 
apical foramen in which he found 37,600 tubules per sq. mm. The 
width of these tubules, according to Koelliker, may be estimated 
as being from 1.5 to 4.5 /*, while the average size of a streptococcus 
is about 1 micro-millimeter, hence we readily understand how these 
organisms find suitable hiding places within the tubules. The root 
canals at their terminal ends near the foramen, as stated above, 
shows marked deviations. Hess has found that in 25 to 80 per 
cent of cases in a Aery large number of examined teeth of all types 
of the human denture from 2 to 5, and some times even more, 
additional foramina could be observed. 

From the clinically observed facts it is evident that the exhaus- 
tion of any medicament sealed into the root canal occurs within a 



224 



DISEASES OF THE DENTAL PULP 



day or two. The Interior of the dentinal tubules cannot be reached 
by the superficially applied antiseptic as aodireci contact is secured, 
hence the quick self-propagation of the retained infective organ- 
Isms which grow luxuriantly into the empty or ill-filled root canal. 
It i- self-evident, therefore, thai the complete mechanical occlusion 
of the root canal in its entirety offers the only absolute guarantee 
for safety as regards reinfection. The complete corking-up of i 
tubule and of every accessor} foramen i- the final desideratum we 
must strive for in the permanent filling of a root canal and thereby 
deposit, as it were, an antiseptic which mechanically occludes the 
confined infective organisms and prevents renewal of their growth. 
The usual procedures at present in vogue with many practitioners 




I "•• 134. Arborisation of the pulp of an upper second premolar near the 
apical foramen. I Fischer.) 

i- t<> leave doubtful canal- unfilled for some time in anticipation of 
some future disturbance. Such unfilled canals, a- experimental 

and clinical evidence clearly indicate-, usually become reinfected 

within a week or two. Hence our tenacious adhering t<> this 

orthodox doctrine: An incipiently infected root canal of a tooth 
/'// situ may he rendered a-eptic upon it- -iirfacc l>y the Use of certain 

antiseptic procedures, hut it i- impossible to sterilize the deep- 
seated infected tooth structure. A- reinfection i- primarily caused 
by organisms left undisturbed in the dentinal tubules, it should be 
an imperative rule with the operator to till at once ;i- completely 

;i- possible even root canal which ha- heen found Sterile upon it- 

surface at the la-t \ i-it of the patient. 



REINFECTION OF ROOT CANALS 225 

In connection with this most interesting problem of reinfection 
of root canals, the question has often been asked: Is it possible 
for microorganisms or drugs to pass through the dentinal tubules, 
through the cementum into the pericementum? The significance 
of such a possibility is naturally of the utmost importance relative 
to the future welfare of the respective teeth. In a recent com- 
munication by Hopewell-Smith 1 we find the following authorative 
statement directly bearing on this subject: 

"Attention must be directed for a moment to the homogeneous 
layer of dentin. Immediately external to the granular layer of 
Tomes, found in the dentin of the roots of human teeth, comes this 
important layer. It is an exceedingly narrow strip of homogeneous 
tissue, which is entirely devoid of any histological elements what- 
soever. It is bounded externally by the first formed cementum, 
internally by the granular layer of Tomes. Its importance will 
be readily conceded when it is pointed out that this homogeneous 
layer acts, by virtue of its position and its structureless character, 
as an efficient barrier to the outward passage of drugs or medica- 
ments placed in the root canal in the treatment of pulpless teeth. 
Assuming that drugs can travel to the utmost extent of the dentinal 
tubes— and it is to be doubted— it is impossible in normal condi- 
tions for them to pass into the cementum and so to the periodontal 
membrane. Thus, fortunately for mankind, one may use indis- 
criminately, and without fear of injuring the cementum or peri- 
odontal membrane, any or every drug of an escharotic or other 
nature. Otherwise, there would always be the possibility of the 
production of inflammation of the periodontal membrane, with 
subsequent loosening and loss of the teeth." 

Bacteriologic Examination of Treated Root Canals.— Before a 
primary infected root canal which has been treated by anyone of 
the conservative methods is ready for the final filling it is impera- 
tive that its sterility should be established. This examination 
should not be made until the clinical evidence warrants the pro- 
cedure. In regard to the microscopic examination of the treated 
canal it must be clearly kept in mind that the examination of a 
smear is less exact and delicate than the cultural control would be. 
Furthermore, it is necessary to realize that the method given below 
merely indicates when not to fill a canal and it does not furnish 
positive information regarding the sterility of the latter. Finding 
bacteria in the smear distinctly contraindicates filling of the canal 
while observing their absence does not mean that the canal is abso- 
lutely sterile. Cultural controls of treated canals which should be 
incubated for at least seventy-two hours will positively establish 
whether a root canal is sterile or not. 

1 Journal of Dental Research, 1920, No. 1, vol. 2. 
15 



226 DISEASES OF THE DENTAL PI LP 

Microscopic Examination of Root-canal Smears. I. Smear widely 
and evenly over a clean slide the dressing obtained From a pool 
canal Immediately upon its removal. 

2. 1 )ry smear in air. 

'•\. Fix by passing rapidly through Same three times. 

4. Stain for three to five minutes with Loffler's alkaline methylene- 
blue solution. 

5. Wash off stain with tap water. 

6. Invert COVer-glass on slide film side down. 

7. Blot dry. 

8. Place drop of cedar oil upon stained film. 

9. Examine with oil immersion lens (1.9 or i 1 . inch . 



CHAPTER XIX. 
FILLING OF ROOT CANALS. 

From a perusal of the early records of the practice of conservative 
dentistry, i. e., the works of Fauchard (1728), Bourdet (1757), 
Hunter (1778), and others, we are informed that whenever a 
"nerve" in a tooth was exposed and diseased, it was destroyed by 
the actual cautery or by a potential caustic, which, however, as 
the keenly observing John Hunter remarks " is not always possible." 
These early writers also referred to the medicinal treatment of the 
"fangs;" the French dentists being especially partial to the use of 
" essence de giroffle" (oil of clove) and Hunter prophetically empha- 
sized antiseptic procedures of a somewhat similar nature as being 
essential for the future preservation of the afflicted tooth. Cotton- 
wool, moistened with oil of clove or some other antiseptic compound, 
was usually sealed into the root canal prior to the final filling of the 
tooth cavity. 

The use of soft metals for the filling of root canals, i. e., gold, 
lead or tin, was instituted later. It is quite certain that the better 
class of American dentists practised root-canal filling at the begin- 
ning of the nineteenth century. In lS2(j the international Koeker 
stated that " the practice of dentistry has reached a state of develop- 
ment in the Tinted States which is higher than in any other part 
of the world, although very little is published by American dentists." 
Fortunately, certain proofs are available to the student of dental 
history which makes it plain that root-canal filling must have 
been a well-known procedure to the high-class practitioner in those 
days, for we find among other data a bill rendered in 1824 by 
Edward Hudson, a prominent Irish dentist, who practised in 
Philadelphia from 1805 to 1833, in which he itemizes "stopping the 
cavity of one tooth from the end of its root with gold." The latter 
material was in common use for such work up to the early seventies of 
the last century and such men as Maynard, Barker, Dunning, Forster, 
YVestcott , Palmer, Evans, McKellops and a host of others, were strong 
advocates of the special fitness of this metal for the above purposes. 
In 1849 the once famous Hill's stopping was introduced as a general 
filling material and it was also advocated as a suitable root -filling 
compound. It was superseded, in 1872, by a solution of gutta- 
percha base plate in chloroform, which, however, was quickly modi- 
fied by employing a solid cone of this same material in conjunction 



228 DISEASES OF THE DENTAL PULP 

with this solution. As a close second, oxychlorid of zinc cement, in 
the early days better known as Houghton's or Robert's os artificial, 
was highly prized by many operators as being the mosl suitable 
materia] for the permanent obliteration of root canals. Prom thi> 
collection of historical data it is apparent thai the closely observing 
practitioners of the past were aware of the fad thai a rool canal 
deprived of its natural contents, /. e. t the pulp, musl be filled 
with some solid substance in order to prevenl subsequent infection. 
The primary object of filling a pool canal Is to replace a> perfectly 
as possible the artificially or pathologically destroyed pulp with a 
solid inert and unchangeable substitute. The specific properties 
of the substances used for such purposes should possess the follow ing 
qualifications: 

1. The material must he non-putrefact ive. 

2. It must he sufficiently plastic to allow it s easy introduction 
and adaptation to all parts of the canal. 

3. It must not change its form after being inserted. 
I. It must l>e Impervious to moisture. 

5. It must seal the dentinal tubules and the apical foramina 
hermetically against bacterial invasion. 

0. It must not discolor the tooth substance. 

7. It must not irritate the soft structures beyond the foramen. 

v It must, in case of necessity, he easy of removal. 

!). It must offer resistance to the roentgen rays so as to furnish 
an opaque shadow picture. 

To enumerate all the substances which have been advocated 
at one time or another as root-tilling materials and to criticise 
their respective usefulness is quite impossible at this moment, as 
a consideration of all the merits and demerits of each compound 

would comprise a small volume in itself. Merely to mention the 
most important groups we may state that silk or cotton, either raw 
or purified, medicated or carbonized, asbestos, tin* cements, metals 
in the form of wire, foil, or as amalgam, gutta percha in it- pure 
form or in its many modifications, wood points, semisolid pastes 
principally composed of zinc oxid combined with various antisep- 
tic-; balsams, resins, waxes, liquid bakelite, etc., have been used 
with more or less success. Clinical observations and laboratory 
experiments have amply demonstrated the fact that out <>f this 
great ma— of suggested materials only a very few substances answer 

the aho\ c demands. 

Silk and cotton in its pure state or in it- many mollification- have 
always been a failure as a root-filling material. In the few cases 

in which cotton fillings have proven to be successful, it must be 

assumed that the chances tor infection were negative or the sterile 

cotton plug neai- the ape\ was sufficiently solid t<» prevent the 
passage of bacteria. Among the various cements, the oxychlorid 



FILLING OF BOOT CANALS 229 

of zinc has been highly lauded and such skilled operators as Jenkins, 
Kells, Ottolengui and others recommended it as being practically 
the most suitable material for this purpose. Zinc oxychlorid 
cement if forced beyond the foramen is markedly irritating and its 
complete removal from a root canal in cases of necessity is often 
impossible. Metals, on account of their imperfect adaptation and 
natural resistance to manipulation in the minute canals have been 
practically discarded. Gutta percha, in the form of cones, in 
conjunction with its solution in chloroform, the essential oils or some 
other vehicle and covered with zinc oxychlorid cement, as Webster 
and Cook have shown experimentally are practically moisture 
proof, and prevent the ingress of bacteria. Cook was rather partial 
to a chloro-percha solution, claiming that a slow liberation of 
active chlorin, which acts as a powerful antiseptic, takes place in 
a root canal filled with this compound, while other practitioners 
prefer a solution of gutta percha in eucalyptol or in any one of its 
isomers, i. e., cajuputol, myrtol, cineol, etc. Laboratory tests 
made with these compounds in glass tubes and in extracted teeth 
have demonstrated that a water-tight filling can be made. If 
sterile gutta percha is accidentally pushed beyond the foramen 
without injuring the soft tissues it will be readily tolerated. In an 
aseptic area it is encapsulated like the proverbial "lead ball." 
Gutta percha is a non-putrefactive substance, sufficiently plastic 
to allow its ready introduction and it will not change its form 
after being packed against solid walls. It may be readily removed 
if need be, and it does not discolor the dentin. In addition, it 
offers marked assistance to the passage of the roentgen rays. In 
general, it may be categorically stated that gutta percha is the 
most satisfactory material for the purpose in view, as it agrees in 
every respect with the above enumerated requirement of a suitable 
root-filling compound. This statement is amply supported by 
clinical experience as gathered from observations covering more 
than half a century. The principle causes of the recorded failures 
may be attributed to an inaccurate technic of its manipulation and 
to improper preparation and treatment of root canals. 

Gutta percha in its various modifications is principally employed 
in the United States and Canada as a root -filling material, while 
in Europe semisolid pastes are still largely employed for such 
purposes. Experimental work with the latter compounds has 
proved that they are valueless ; they prevent the ingress of sepage 
only temporarily. Wooden points, either artificially prepared or 
in the form of natural thorns or as charcoal or fiber points, are 
porous and consequently are useless substances. Salol, when 
melted into a root canal, will be absorbed within a short time. 
Some of the balsams, i.e., Canada balsam, balsam of Peru, balsamo 
del Desert o, concentrated solutions of sandarac and other resinous 



230 



DISE iSES OF THE DE \ / \L PI 1. 1' 



compounds, arc still lauded by many practitioners*. The solid 
rc>in> possess man} advantages over other compounds; their 
successful introduction into fine root canals Is very difficult. In 
very thin solution-, however, they arc most excellent adjuncts. 
Within the last deceniums high fusing paraffin has been favorably 
recommended as possessing ;ill the enumerated qualities. It has 
been claimed that the paraffin Is absorbed from root canals and, 
consequently, Infection of the empty canal may occur at some future 
period. The writer is under the impression that in most instances 
the spaces occurring from supposed absorption have never been 
correctly filled or that a low-fusing paraffin had been employed. 
Satisfactory roentgenologic controls of ten and more years' service 

of root canals tilled with hard paraffin containing oil per cent 
bismuth oxid are sufficient proof of this assertion. 





I'm.. 135. < 'in ta-percha 



Fio. L36. Bard paraffin root canal 

filling. The roots were filial four- 
teen years ago with hard paraffin- 
bismuth compound and the tooth i- 
still in position on May 2, 1921. 
(Dr. Arch. Miller. 



The addition of antiseptics to insoluble substances, i. c, gutta 
percha, cements, etc., which are used as root-filling materials has 
practically very little value. Theoretically, antiseptic action 
indicates that the substances must become soluble, or to speak 
more correctly the pharmacologic action of a drug i> manifested 

only when the drug enters the tissues as a liquid or in gas form. 
When a solid drug is introduced it necessarily follows that it must 
be soluble in the tissue fluids if its typical action is to he mani- 
fested. Since gUtta percha and other similar substances are insol- 
uble in the l)od\ juices, they prevent the solution of the drug or 
drugs which are dissolved in or Incorporated with them. The 
insoluble porous root-filling material, i. e. t cotton, wooden points, 

various cements, semisolid pastes, etc., containing a soluble anti- 
septic <'Her> no resistance to the invading surrounding fluids; it 
will be exhausted in due time. This statement is sufficiently sub- 
stantiated l>\ clinical observation and experimental work, [nocu- 



FILLING OF ROOT CANALS 231 

lated plate cultures in which cones of sterile gutta percha contain- 
ing reasonable quantities of thymol, mercury bichlorid, bismuth 
oxid, iodoform, etc., are suspended, show a more or less tiny zone 
of inhibition of bacterial growth within their immediate periphery. 
It is an indication that some of the antiseptic material deposited 
upon their surface has entered into solution. But these small 
quantities of the antiseptic are too minute to be regarded as being 
of permanent value. No bacterial growth is observed upon sus- 
pended pure sterile gutta-percha cones. If we wish to cover a root 
canal with an antiseptic it seems more reasonable to apply this 
antiseptic as such or dissolved in a volatile medium prior to the 
insertion of the final solid canal filling. Of the many antiseptics 
which, relatively, possess permanent action, comparatively few 
answer our purpose. A normally liquid antiseptic is not as well 
suited as one which can be deposited in dry form and which slowly 
dissolves in the moisture present in the dentinal tubules. It should 
be borne in mind that no substance will enter the dentinal tubules 
of a tooth root in situ at once, on account of the present moisture; 
it requires a more or less prolonged period of time (days and weeks) 
to accomplish this process and it should also be remembered that 
experiments regarding the penetrability of antiseptics made with 
teeth out of the mouth do not represent normal conditions and are, 
therefore, misleading. From experimental work we are led to 
believe that aceton is a fluid which is especially suited as a carry- 
ing medium of antiseptics on account of its ready affinity for 
water, its solvent action upon fatty substances, its penetrating 
power, its hardening effect on tissues and its ready evaporization. 
Aceton is a colorless mobile and volatile liquid having a charac- 
teristic ethereal odor and a pungent sweetish taste. It volatilizes 
at a low temperature and boils at about 133° F. (56° C.)- It is 
readily soluble in water, alcohol, ether, chloroform and the volatile 
oils. 

We again emphasize that, according to our conception, the object 
of a root-canal filling consists in sealing hermetically the foramina 
and the tubules with a solid, inert and unchangeable substance. 
The com pi etc obliteration of the canal is the only logical solution of 
this problem. The sealing of the dentinal tubules is of paramount 
importance since reinfection of a root canal is probably always 
due to the renewed activity of those microorganisms which lodge 
within the dentinal tubules and which cannot be destroyed by 
surface disinfection. 

At present it is generally conceeded that the solid obliteration of 
a sterile empty root canal with gutta percha, from a clinical point 
of view, offers serviceable chances against reinfection. The diffi- 
culties encountered in obtaining the desired results rest primarily 
with the mechanism involved in the complete occlusion of small 



232 DISEASES OF rill'. DENTAL PULP 

tortuous canals and not with the material. Hence the important 
dictum: Ever} pool canal must l><\ it possible, mechanically 
enlarged to its very apex. To facilitate the ready introduction of 
gutta percha, its solution in various solvents, especially in chloro- 
form or eucalyptol, have been advocated. It is ;i well-known fact, 
however, that such solutions on the evaporation or resorption of 
the solvent must naturally shrink. The empty space produced bj 
the shrinkage leads, as we have stated above, to reinfection. On 
the oilier hand, it is also proven thai when such solutions are used 
in minute quantities merely as lubricants for the -una percha cone 
and by applying sufficient force in the final packing a perfect 
adaptation of the semiplastic gutta percha is obtained 30 as to 
produce an absolute water-tight filling. The clinical success 
obtained with this procedure in the hands of expert operators 
is ample proof of the soundness of this statement. It must be 
admitted that not every operator possesses this superior dexterity 
which, however, must not be construed a- shielding slovenly 
work in regard to the too liberal use of gutta-percha solutions as 
well as insufficient care in the final packing. 

To further facilitate ready obliteration of minute spaces left by 
an ill-adapted gutta-percha cone, the late Callahan, in l!Hi). intro- 
duced a most ingenious combination of root-canal technic consist- 
ing of the use of a very thin resinous solution in conjunction with 
the usual gutta-percha cones. Callahan stated in his diverse 
writing: It required a long time for me to realize the advant 
in the use of a thin solution. A thick mixture will not penetrate 
the tubules nor does it give up enough chloroform to dissolve 
gutta percha. The use of a very thin rosin solution is the most 

e»eiitial feature of his discovery. However, it should be borne in 
mind that if one depends upon the solvent action of the chloroform 

upon gutta percha the evaporation of the solvent naturally pro- 
duces shrinkage and hence, an empty space between the cone and 

the wall of the canal results. If. on the other hand, the thin rosin 
solution is allowed to percolate into the previous dehydrated den- 
tin and the solvent is evaporated prior to the final filling of the 
canal, no shrinkage w ill occur. 
Callahan advocated the following solution for such purposes: 

b violin p.-in 12 grains 75 

Chloroform :< drama l-' "<i gm. 

Neither the nature of the rosin or its solvents arc essential features 

of the solution. Any good rosin and a suitable solvent of a \ ery 
low boiling-point answer the purpose eqtialK well. 'I he writer 
prefers ;i good, clear rosin dissolved in aceton. If a neutral solu- 
tion of the normally slightly acid rosin is desired a few grains of 
sodium bicarbonate niav be added. After the dehydrated dentin 



FILLING OF ROOT CANALS 233 

is saturated with this thin rosin solution and the solvent has evapo- 
rated, the dry glazed interior of the canal is coated with a very thin 
film of a suitable lubricant to facilitate the ready placing of the 
final gutta-percha cone. A solution of gutta-percha base plate in 
paraffin oil, equal parts, is most serviceable for this purpose. This 
solution does not shrink as it will not evaporate. Again it should 
be emphasized, that this paste merely acts as a lubricant and that 
only the smallest possible quantity should be employed. 

The rationale of this method of filling root canals may be 
explained upon the following basis: The dehydrated dentin 
offers good chances for the ready percolation of the very thin rosin 
solution into the dentinal tubules to the depth of a few millimeters 
which thereby are corked up. In addition, the canal itself is 
tightly obliterated by a solid packing of gutta percha against a 
sterile glazed surface. 

In using a solid cone for filling a root canal the question is often 
asked: What becomes of the confined air? This little air when 
forced beyond the foramen will be taken care of by the soft tissues 
and since it is not forced into a vessel, no danger from air embolism 
is to be expected. That such small quantities of air, even if injected 
into a vessel, are practically free from danger, has been experiment- 
ally demonstrated by Blair and McGuigan. 

Experimental work carried out on freshly extracted teeth shows 
that the mechanism of dentin infiltration, etc., as outlined above 
actually occurs. If the rosin solution is colored with Sudan red, 
ground stained sections of the root show its deep penetration into 
the dentin. If the teeth, whose root canals have been filled accord- 
ing to the outlined method, are immersed in methylene-blue solu- 
tion and by a glass tube sealed into its pulp chamber are connected 
with a suction pump under water pressure, it will be found that 
an absolute water-tight, root-canal filling can readily be obtained. 

Technic of Filling Root Canals.— A systematic analysis of the 
various steps involved in the practice of filling root canals as based 
upon our previous discussion in regard to reinfection, resolves itself 
into the following procedures: Dehydration of the sterile root 
canal, infiltration of the dentinal tubuli with a very thin rosin solu- 
tion, evaporation of the rosin solvent, coating of the varnished 
canal walls with a thin film of gutta-percha paste, the final solid 
plugging with pieces of gutta percha and filling of the pulp chamber 
with zinc oxychlorid cement. A final roentgenogram is essential 
for checking-up the operation. 

Dehydration.— The sine qua non of a successful root-canal filling 
is an absolutely dry root canal. To accomplish this end, certain 
physical procedures are in vogue, i. e., the hot air blast, the electric- 
ally heated root dryer, the heated wire, of which the Evans' root 
dryer probably is the best known prototype, bibulous paper cones, 



234 



DISE iSES OF THE DE1\ I'M. I'l I.I' 




cotton, etc. To Facilitate the removal of moisture, 
hygroscopic chemicals, i. e. s alcohol, chloroform, ether 
aceton and other substances, arc often used in con- 
junction with the above enumerated mean-. These 
compounds, with the exception of aceton and alcohol, 

have little affinity for water and hence are of no 

practical value. As we have stated above, aceton 
or absolute alcohol is admirably suited for this pur- 
pose. In drying out a root canal it should be borne 

in mind, that the removal of it> natural moisture or 
any other fluid placed into it is well-nigh impossible 

with the much landed hot-air blast if the foramen 
is closed. A few trials on an extracted tooth or a 
ula>> tube drawn out to a fine solid point and filled 

with water or any other of the above enumerated 
fluids will readily convince one of this illusoric 
conception. The fluid will move hack and forth 
upon the elastic cushion of air confined in the end 
of the tooth or the tube, or, if no air i- present the 



Fig. 138. Riethmflller rool dryer. 



U 



heated air blast will practially make no impression on 
the moisture column. The removal of moisture i- 
usually besl accomplished by using bibulous paper 
cones in conjunction with a heated metallic root- 
canal dryer. The cessation of the hissing sound 
following the Introduction of the hot wire indicates 
that the desired effect ha- been successfully achieved. 
In passing, it i- well to remember that over-drying 
the tooth structure is a dangerous procedure. If 
more or less of the water which holds the gelatinous 
matrix of the tooth in colloidal solution i- removed 
l>\ over-heating, that tooth i- proportionally weak- 
ened against physical or chemical insults, a fact 
which i- well I) >rne out by clinical observation. 
Infiltration of tin Dentinal Tnhnli with a Thin 

Rosin Solution. The solution required for this pur- 
pose consists of: 



I{'>-in .... 

Sodium bicarbonate 
Aceton . . . . 



1") grains 1. 00 gm. I 
t grains 25 

■2 ounce i"' "n 



137 

I 



Decant the clear solution and keep in a we 
stoppered bottle. 



FILLING OF ROOT CANALS 235 

With a paper cone the solution is pumped into the root canal 
immediately after dehydration and the aceton is evaporated with 
the warm air blast. If necessary, the process is repeated so as to 
have a fair assurance that every tubule is sealed. 

Coating the Canal with a Gutta-percha Paste.— X most suitable 
paste for this purpose which will not shrink is prepared as follows: 
i ounce of gutta-percha base plate cut into small pieces is put into 
a suitable perfectly dry wide-mouth bottle and covered with J 
ounce of a colorless pure paraffin oil (nujol, etc.). The bottle 
containing the mixture is placed on a heated sand bath until com- 
plete solution is obtained. On cooling, the mixture has the con- 
sistence of butter in cold weather. With a broach a very small 
quantity of this paste is transferred to the varnished canal and 
spread over its wall. A blast of warm air will greatly assist in 
its even distribution. The object of using this paste is primarily 
to place a lubricant into the canal to facilitate the ready adapta- 
tion of the gutta percha under pressure, and secondarily to occlude 
every nook and corner by an unshrinkable material. We again 
emphasize that only the smallest possible quantity of this paste must 

be employed. 

Final Plugging of the Root Canal. — Before starting the final opera- 
tion of plugging the root canal the roentgenogram with the diag- 
nostic wire in position is carefully examined so as to obtain a fair 




Fig. 139.— Glass contained for gutta-percha cones. Gutta-percha cones cut in short 
lengths ready for use. (Coolidge.) 

conception of the size, general outline and length of the canal. To 
approximately determine the size of the foramen, a suitable sterile 
root-canal plugger is selected and inserted. Too small a plugger 
will pass through the foramen which is indicated by pain. The 
correct instrument should pass up to, but not quite to the foramen. 
A very small piece of rubber dam stretched over a smooth broach 
may be used as a guide to determine the length of the canal. A 
suitable sterile gutta-percha cone which approximately fits the 
lumen of the canal is selected from the cone sterilizer and is cut 



230 



DISEASES OF THE DENT \L IT Li 



into pieces about j inch (.3 nun.: in length. A suitable piece which 
approximately will lit the upper end of the canal as determined by 

ml ol 
gutta 
percha must never he touched w it ii th" lingers, i he piece is slo* ly 
hut very firmly pressed to place. Slow, firm and persistent 
pressure is imperative so as to drive the piece, if possible, 



into pieces aooui § men i.. nun.: m lengui. .\ smtauie piece w\ 

approximately will lit the upper end of the canal as determine' 

the plugger point is -elected, mounted upon the warmed en< 

the Sterile canal plugger and carried to the canal. Tip 

percha musl never be touched w ith the fingers. The piece is sin 

Kilt verv firmlv nr4»OQAn tn nl:iee Slnw firm :iiwl ru>raial 




Fio. 1 1 () . Root oanal plugg 

to the very apex or even slightly beyond it. Under the persistent 
firm pressure the semiplastic gutta percha will adapt itself to the 
irregularities of this region. The placing of the initial piece of 
gutta percha ia the most important part of the entire operation of 
filling a root canal and not too much emphasis can be put upon 
carrying out its correct technic ><> as to obtain the desired results. 
The hermetical sealing of the foramen without injury to the peri- 



FILLING OF ROOT CANALS 



237 



apical tissues is the unalterable prerequisite upon which the future 
welfare of the tooth rests. Clinical experience has amply demon- 
strated the fact that this small quantity of sterile gutta percha which 
accidentally may pass beyond the foramen is too insignificant to 
be productive of serious consequences. The remaining portion of 
the canal is solidly filled in the same manner with gutta percha 
bits as needed, using larger root-canal plugger and the pulp chamber 
is finally occluded with oxychlorid of zinc cement. A roentgeno- 
gram may now be taken so as to check up the operation. If the 
root-canal filling is in any way defective it should be removed. 
The application of chloroform or xylol to the gutta percha 
assist in softening the cone and thereby facilitate its removal. 
The canal should be refilled at once as outlined above and a second 
roentgenogram is taken to show whether the operation is a success 
or failure. 






A B C 

Fig. 141.-^4, filled to the end; B, crater filled; C, apex capped. 



(Crane.) 



Summary of Filling Root Canals.— 1. Carefully examine the 
roentgenograph taken with diagnostic wire in position prior to 
filling the canal in regard to its length, size and general outline. 
Determine the size of the foramen with a root-canal plugger and 
the length of the canal with a smooth broach having a small piece 
of rubber dam attached to serve as a guide. 

2. The suitably enlarged canal is dried with sterile paper points, 
followed by aceton or absolute alcohol and the hot root dryer. 

3. Infiltrate the dentin with the rosin-aceton solution carried 
upon a paper cone and dry with warm air. 

4. Apply a very small quantity of gutta-percha-paraffin oil paste 
on a broach. A touch of warm air will facilitate its even distribu- 
tion. 

5. Select a sterile gutta-percha cone and cut it into pieces about 
| inch in length. Select a suitable piece, mount it upon the warmed 
sterile root-canal plugger and carry it to the canal. Do not touch 
the gutta-percha cone with the finger. Apply slow but very firm 
and persistent pressure. Fill the remaining portion of the canal with 
gutta percha bits in the same manner, using larger canal pluggers 
as needed. 

0. Fill the pulp chamber with oxychlorid of zinc cement. 
7. Have a roentgenogram taken to check up the operation. 



CHAPTER XX. 

ACCIDENTS ARISING IX THE TREATMENT OF 
ROOT CANALS. 

I. THE BREAKING-OFF OF INSTRUMENTS IN ROOT 
CANALS. 

I\ the process of mechanically cleansing a root canal of Its 
contents it occasionally happens that a broach or other -ted instru- 
ment will break and remain lodged ill the canal. An accident of 
tin- type should not always he attributed to the awkwardness of 
the practitioner; it may occur at any time even in the hands of 
the mosl expert operator. On the other hand, it should be stated 
that certain precautionary measures may obviate, or at least 
materially reduce the possibilities of such accidents. In general, 
one should be mindful of the fact that the principal danger of 
breakage lies within the very delicate nature of the Instruments 
;i- utilized for the purpose in view. As a consequence, it behooves 
ns to purchase only the very best quality of root canal Instruments 
and to carefully test them in regard to temper, flexibility, etc., 
prior to their employment. 

'To further obviate the possibility of breakage the use of engine- 
driven root -canal Instruments of a delicate type, i. e., Gates-( Hidden 
drills, etc.. should he discouraged; they are largely and correctly 
supplanted at present by improved hand instruments, especially 
files, etc. Of the various hand instruments, aside from broaches, 
the root-canal reamers furnish the largest quota of breaks. The 
very nature of their construction, being in reality modified forms 
of twist drills, favors their ready fracture. It is claimed by Clawsen 
that if the broach i- inserted and held in such a manner that pres- 
sure maj be produced upon the broach toward the ape\ of the POOt, 
SO that the -tell) of the broach i- free from all edges of the cavity 

and not allowed to rest against any edge during the rotation, the 
broach may be rotated at will, reducing the danger of breaking 

; least .",ii per cent. In removing the broach, slide the fr 
to the opening of the cavity and raise the broach with the finger 
,it that poim. thus avoiding anj binding upon the edges of the 
c.i\ ity, and rendering the remoA al of the broach yerj easy and sure. 
The various methods at our command \'<>\' the removal of broken 
instruments from root canal- ma\ conveniently be divided into 
mechanical measures, chemical method- and surgical procedure-. 



ACCIDENTS ARISING IN TREATMENT OF ROOT CANALS 239 






Mechanical measures intent to remove the broken part by manipu- 
lative skill and the various methods utilized for such purposes 
should always be employed at first in preference to any other pro- 
cedure. If the broken piece can be grasped and removed with 
suitably shaped delicate pliers, of course, the 
incident is closed. If, on the other hand, the o 

attempt fails, additional means may be called 
to assist in the effort. A very few fibers of 
cotton may be loosely wound about the finest 
barbed broach and introduced into the canal 
alongside the broken piece. By turning it to 
the left, the piece may become entangled in 
the cotton and thus its removal is occasiona Un- 
successfully accomplished. William H. True- 
man described the following device for such 
purposes: Taking a piece of fine brass wire, 
such as is used to keep open the needle of a 
hypodermic syringe, he formed upon one end 
a spiral of a few turns by winding it upon an 
instrument about the same size as the broken 
one and securing the other end to any small 
tool with gum shellac. This spiral he' placed 
over the broken instrument in the pulp canal, 
pushing it well down with a broach. Upon 
gently withdrawing it, the coils of the spiral 
tightened upon the broken instrument, hold- 
ing sufficiently firm to effect its removal. 

Trueman's device furnished the prototype 
for the so-called Beutelrock broken instrument 

o ® ® US 



J 



Beutelrock's instruments for the removal of 
broken broaches. 



Fig. 143.— Split and 
threaded instrument for 
engaging the shank of a 
Gates-Glidden drill. 



removers which may be obtained in various sizes. To facilitate 
the ready application of these wire spirals, small trephines are 
furnished with the Beutelrock set. A somewhat similar tool 
especially designed to remove a broken Gates-Glidden drill has 
also been on the market. This extractor has a split and threaded 
cone socket, which, when carefully pushed and turned in the canal 



240 DI8E \SE& OB THE DENTAL PI LI' 

will seize the broken drill-shank and effect its extract ion. In some 
cases it may l>e best to first enlarge the canal before Inserting the 
extractor. 

Crane suggests the following procedures: Broken instruments 
(•tier the greatest difficulty of any canal obstruction. It may be 
here pointed out, however, that this does not apply to smooth 
instruments broken off in the picking and pushing motion. If 
these are simply ignored for the time being and the picking and 
pushing resumed with a new instrument, the broken portion will 
soon ride out of the canal, but where an instrument is broken while 
being screwed into the canal further exploration is often impossible. 
By repeated use of sodium-potassium on a root pick, it is sometimes 
possible to make a pathway alongside of the obstruction, and then 
a twist broach may be passed into this and twisted around and 
around to the right, without permitting it to advance into the 
opening. When this does not work it is feasible occasionally to 
continue the picking alongside of the broken instrument and reenter 
the canal at a point apical to it. 

YYass 1 employs an aqueous solution of iodin trichlorid and he 
gives the following direction for its application: "The 25 per cent 
aqueous solution is used for the purpose of dissolving broken-off 
steel instruments of any sort which may be found in root canals 
and which cannot be dislodged by mechanical means. Only tanta- 
lum- or platinum-pointed instruments or a platinum-pointed 
dropper or syringe should be used in applying the solution. The 
action of ICla when it comes in contact with steel or iron is to form 
ferrous iodid and ferrous ehlorid, both of which salts are soluble 
in water. Its action is definite and very rapid if sufficient surface 
of the metal is exposed, and may be tested by dropping a breach 
in a little of the solution. In a canal, however, it has only the cross- 
section of the broken metal to attack and it will often require more 
than one visit and patient technic to either reduce, say, a broken 
broach, sufficiently in circumference so that it will drop out of the 
canal, or to entirely dissolve it. Therefore, it is necessary to drill 
around the exposed end as much as is sab 1 , so as to expose ;i^ much 
metallic surface to attack as possible. Apply a small quantity of 
the 26 per cent solution of trichlorid of iodin around the broach, in 

the canal and allow it to remain for three minnto. Absorb this 
with paper points, wash out with distilled water and dry around 
the broach with cotton wound on a broach, removing any remain- 
ing ferrous coating. Dry with air blast and pick around the 
instrument with Rhein picks. Apply Ids again for three minutes; 
absorb, wash, dry, pick and enlarge the space around the instru- 
ment again, and repeat until the entire obstacle is removed. II 

1 Dental < tamos, « tetober, 1918, p. BOS. 



ACCIDENTS ARISIXG IN TREAT ME XT OF ROOT CANALS 241 

the tooth under treatment is an anterior tooth, where any dis- 
coloration must be avoided, the best procedure is to flow a small 
quantity of melted paraffin over the dentin which lines the labial 
enamel— in other words, the labial coronal dentin. This will not 
interfere with the action of the IC1 3 in the canal, and the crown 
of the tooth will not be stained. In posterior teeth, if there is any 
reason, remove the stain, it can be best accomplished by applying 
a strong aqueous solution of ammonia followed by a saturated 
aqueous solution of sodium hyposulphite." 

Iodin trichlorid is a most powerful caustic which requires the 
greatest care in handling. From his experience with this com- 
pound, the writer is under the impression that the danger associated 
with its application for the purpose of dissolving broken-off broaches 
is too great to merit its general adaptation by the average practi- 
tioner. 

Some years ago, while determining the solubility of dentin in 
the various mineral acids for the purpose of assisting in the open- 
ing of obliterated root canals, the writer 1 observed that the most 
satisfactory acid for such purposes is a 50 per cent nitric acid or a 
.">(> per cent nitro-hydrochloric acid. Incidentally, it was observed 
that while the diluted nitric acid would rapidly dissolve a steel 
broach, the pure acid would do so only very incompletely, or, at 
least, very much slower. Furthermore, the peculiar fact became 
manifest, which however, as later inquiries revealed, was being 
known to chemists, that the solvent action of the respective dilu- 
tion of the acid upon steel was restricted to very limited bounds. 
For example, pure nitric acid may require many hours to dissolve 
a piece of steel broach of a given weight and size, while a piece of 
the same character will completely dissolve in a 50 per cent solution 
of this acid within ten minutes and only slightly so in a 25 per 
cent solution. It should be understood that the term percentage 
solution as referred to these diluted acids indicates measures by 
volume. While experimenting with the various halogens for the 
purpose of sterilizing infected root canals by ionization, it was 
observed that when a steel needle was used in the presence of a 
concentrated Lugol's solution, invariably, an iron iodid or iodate 
was formed. In other words, the insoluble steel in the presence 
of liberated iodin was changed into a soluble salt. It was found 
that a few drops of a solution having the following composition will 
dissolve a piece of steel broach of average thickness and measuring 
I inch in length within thirty minutes: 

Potassium iodid 2 drams ( 8 gm.) 

Distilled water 3 drams (12 gm.) 

After complete solution add, 

Iodin crystals 2 drams ( 8 gm.) 

1 Prinz, H.: Dental Cosmos, 1922, p. 1105. 
16 



242 DISEASES OF THE DENTAL I'l LP 

Keep in a glass-stoppered bottle. The bottle should be prefer- 
ably kept in a tightly closed lox and stored in the laboratory as 
the iodin funics which may arise therefrom are highly destructive 
to steel instruments. The solution does nol deteriorate with 

It is necessary to realize the fad thai a broken piece of steel as 
wedged in a root canal presents to the attacking solvent merely 
a cross-section of the broach, i. e. s an extremely small surface, 
hence the solvent requires a much longer time for its action. In 

addition, absolute contact between the steel and the .solvent is an 
imperative necessity and while this most important fad i 
evident, nevertheless, it is frequently overlooked and it was found 
to be the principal cause of recorded failure.^. To obtain as large 
a surface of exposure as possible, the preliminary application of 
diluted nitric acid to the root canal is strongly recommended. The 
acid naturally has a greater affinity for the less resistant dentin 
than for the steel; as a consequence, the dentin surrounding the 
piece of steel is readily decalcified. A drop of oil per cent nitric 
acid when worked into a root canal with a platinized gold broach 
usually i^ completely neutralized in less than ten minutes. In 
clinical practice a drop of the diluted nitric acid should he worked 
into the canal about every two minutes until the canal is fairly 
filled. The acid is now neutralized with sodium dioxid carried on 
a barbed broach wound with a few fibers of asbestos and dipped in 
alcohol. The resultant evolution ^ oxygen often loosens the piece 
sufficiently that it may he washed out by a stream of water from a 

syringe. If, however, the piece is not dislodged, the concentrated 
iodin-potassium iodid solution as given above should now be 
applied. T<> prevent undue dilution of this solvent all the moisture 
has to he removed from the root canal. As the compound readily 
destroys -teal, it is best applied with an eye dropper and worked into 
the canal with a platinized gold broach. Finally, a few fibers of asbes- 
tos are saturated with the solution and packed into the canal and the 
cavity is carefully sealed with temporary cement. The application 

should remain undisturbed for at least twenty-four lours. On 
return of the patient, the contents of the canal are washed <>ut 

and with a fine barbed broach wound with a few fibers of cotton 
an effort is made to remove the debris. If the piece of broach is 

not completely destroyed a second or a third treatment may he 
applied ;i- needed. 

In spite of the various suggested mechanical and chemical 
methods, the removal of a broken broach from a root canal will 

lot always he crowned with success. As a final desideratum, surg- 
ical procedure- may l>e instituted. While in all cases of this 
character a <:»">d roentgen picture is most desirable; it is of impera- 
tive necessity for the surgical methods. The exact location of the 
broken piece will naturally guide the clinician in the specific technic 



ACCIDENTS ARISING IN TREATMENT OF ROOT CANALS 243 

selected for the respective case. Williger 1 advocated excision of the 
root apex in such instances, and he proceeds as follows: Resection 
is most easily performed in upper anterior teeth, in which removal 
of a foreign body is most necessary. The tooth is opened far 
enough to allow the easy introduction of a straight root-canal 
plugger into the root canal. Under local anesthesia and anemia 





Fig. 14-i. — Broken broach in root 
canal. 



Fig. 145. — Broach removed by 
iodin-potassium-iodid solution and canal 
filled. (Dr. John Burkhardt.) 



the root apex is exposed and resected as far as indicated, and the 
foreign body is pushed through the root canal with the root-canal 
plugger or a cut-off Miller broach in a broach-holder, until it can 
be grasped with pincers and extracted. The root canal is then 
cleaned with hydrogen dioxid and filled. If a broach has been in 
a canal for a long time it breaks easily in removal and must fre- 
quently be extracted in several pieces, together with a quantity 




Fig. 146. 



-Broken broach above 
foramen. 




Fig. 147. — Appearance of tooth 
four weeks after the piece had been 
removed surgically by Dr. R. Foy. 



of oxidized debris. In such cases the root shows dark blue dis- 
coloration. If no granuloma or cyst is noted after incision and 
exposure of the root apex, a shallow groove is burred in the bone 
in the longitudinal axis of the tooth with a strong, straight fissure 
bur. Through this groove the broach can be pushed out, grasped 



Dental Cosmos, December, 1912, p. 1289. 



24 1 DISEASES OF THE l>i:\ TAL ft LP 

and extracted. In firsl and second molars this method is rarely 
applicable. Instead, the t<><>tli is extracted, the foreign bodj 
removed and the tooth replanted under aseptic precautions. 

II. PERFORATION OF A TOOTH ROOT. 

Perforation of the rool of a tooth may be broughl about by 
an accident, i . < .. the misguided drill or reamer may pass through its 

wall during the process of opening up a canal or in excavating 
deep-seated caries the Instrument may cause a parietal perforation 
through softened dentin. The accidental perforation should not 
always be attributed to the awkwardness of the operator. In the 
majority ^\' <-a>e^ the injudicious use of engine drills or hand instru- 
ments, especially by the inexperienced student, i> probably most 
frequently responsible for such accident-. 

In conformity with it s position we may differentiate between a 
parietal and an interradicular perforation and according to its 
etiology, we maj speak of a traumatic or pathologic perforation. 
While the parietal perforation which i^ usually the result of a 
trauma ma\' occur anywhere between the pulp chamber and the 
apex of the root, the interradicular type IS only observed within 
the pulp chamber of multi-rooted teeth and it is usually the sequence 
of some pathologic process, i. e., caries. The passing of the broach 
through the apical foramen should not be designated as a perforation. 

The subjective symptoms of a root perforation are usually rather 
definite. /. i ., the perforation it-elf i> not painful, hut on passing a 
probe through the opening into the pericementum, the patient 
feel- a distinct painful sensation resembling the prick of a needle 

within the gum tissue. The character of the pain i- distinctly 

different from that experienced in pulpitis or pericementitis and it 
becomes altered with the development of secondary infectious dis- 
turbances within the alveolus. Granulation tissue which may 
protrude through a pathologic perforation should l>e carefully 
differentiated from pulp tissue. A recent perforation is always 
accompanied by rather profuse hemorrhage. 

If the perforation is situated in the pulp chamber or in the lower 
pari of the root it may !><• frequently observed directly or by the 
aid of a mirror. The opening, on passing a broach, is distinctly 
felt l>; the guiding Bngers and it - w it Ik I raw al usually is followed by 
free bleeding. In deeper perforations the diagnosis is usually 
wrought with difficulties. In such cases a roentgenogram with 
the diagnostic wire in position is an imperative necessity. 

\ differential diagnosis between a perforation and a pulpitis or 
a pericementitis is readih made by comparing the various symptoms 
a- discussed under " ( reneral Principles of Diagnosis." 

I he prognosis of a perforated root depends entirely upon existing 



ACCIDENTS ARISING IN TREATMENT OF ROOT CANALS 245 



conditions. If the perforation is of recent occurrence and located 
within an easily accessible region in a strong, sound root and if 
no suppurative infection of the pericementum is to be observed, 
the prognosis is rather favorable, while in opposing conditions the 
operator should not be too sanguine in his expectations. In the 
latter instances the successful closure of the opening always remains 
an operation of chance. 

The treatment of a perforation must be based upon the possi- 
bility of establishing asepsis within the perforated wall and the 
surrounding tissues. While it is not necessary that all perforations 
should indicate actual sepsis, it is, nevertheless, important to look 
upon an exposed root canal as being infected. Whether the per- 




Fig. 148. — Two parietal perforations. 




« | 1^, ^ 



Fig. 149 Fig. 150 

Figs. 149 and 150.— Parietal perforations. 

foration should be closed before or after the treatment of the root 
canal depends upon conditions. Usually, asepsis of the canal should 
be established prior to the closure of the false opening. 

The primary aim of treatment should be directed against stopping 
an existing hemorrhage. Strong caustics must be avoided. The 
tight plugging of the canal with cotton moistened with a mild 
antiseptic, i. e., camphorated phenol, etc., and sealing its orifice 
with temporary stopping for a day or two is usually sufficient. 
After asepsis of the canal is established in the routine manner the 
closure of the perforation becomes now imperative. In deep-seated 
regions in which the opening through the wall cannot be directly 
viewed, the root canal should be filled with a non-irritating aseptic 



240 



DISEASES OF THE hi \ TAL PULP 



material which can be rendered semiliquid by heal at the time of 
it- application. Hard paraffin is most serviceable for this purpose. 
A suitable compound may be prepared a- follows: 



Bismuth subnil i 

Hard paraffin (about 130 1 



r 



<-■) 



5J i I 



Heat the paraffin to about 250 F. 120 C. for half an hour to 
insure sterility; let it cool t<» about 150 F. and add the 

bismuth under con-taut stirring. I in nclt the solidified mixture and 

-tir well tu in-iirc a homogeneous union. Pour upon a glass slab 

and at't<r cooling remove, cut in -trip- and preserve in a wide- 
mouth Itottle. 





i:»l 152 

I I'.s. 151 and 152. — Interradicular perforations. 




il'Ii the foramen i m < > 1 1 * < - antrum — not a perforation. 



The initial steps for the preparation of the root canal prior to 
it- filling with paraffin arc the same a- those discussed in the pre- 
vious chapter. Complete dryness of the canal for tin- purpose is 
tial. \ cone-shaped piece of the hard paraffin is inserted in 
the root canal and the heated root dryer i- pa--ed along it- side 
opposite the perforation. H> a gentle pumping motion the air i- 
expelled and the semiliquid paraffin is coaxed into the canal and 
the perforation. Care should be exercised not to overheat the 
paraffin, although it i- essential to keep the root dryer fairly warm 
chill the compound. A. jet of warm air applied during 
the filling procedure materially assists in keeping the paraffin -"ft. 
■• rilt- gutta-percha cone with it- tip cut off ina\ now be 



ACCIDENTS ARISING IN TREATMENT OF ROOT CANALS 247 

introduced and pressed to place, thereby acting as a core and insur- 
ing a more perfect adaptation of the softened paraffin to the irregu- 
larities of the canal. The final closure of the canal is the same as 
in an ordinary canal filling. A roentgenogram of the finished 
operation will furnish a distinct shadow picture of the bismuth- 
paraffin root filling and it will indicate whether the perforation has 
been successfully occluded. 

If the perforation is visible it is, of course, more easy to close 
the aperture. Sometimes a thin bladed burnisher may be inserted 
between the pericementum and the opening or into the bifurcation 
of the roots in an interradicular perforation. The thin blade acts 
as a matrix. Visible perforations are best closed with soft copper 
amalgam. Should there be any objection to the use of amalgam 
the opening may be sealed with a suitable piece of metallic foil 
dipped into a varnish or into thin chloro percha. A specific influ- 
ence of the respective metals used for such purposes, i. r., platinum, 
gold, lead, etc., upon the success of the operation aside from their 
varying degrees of adaptability must be denied. If the perforation 
is caused by caries the dentin within the vicinity of the false open- 
ing should be saturated prior to its occlusion with a 2 per cent silver 
nitrate solution. 

If the perforation is located near the apical region and has not 
been successfully occluded as demonstrated by a roentgenogram, 
amputation of the involved root may be performed, provided the 
general conditions of the tooth justify such a procedure. 



III. ROOT CANAL FILLING MATERIAL WHICH HAS PASSED 
BEYOND THE FORAMEN. 

Root-filling material which has been forced into the periapical 
tissue during an attempt of filling a canal occasionally causes dis- 
turbances within this region by irritation and if it is not aseptic it 
naturally will be the cause of a future infection. Of the cements, 
the oxychlorid is probably most frequently employed as a root- 
filling material. If a small quantity is passed above the foramen 
it is usually followed by more or less painful irritation lasting for 
about twenty-four hours. Only when large quantities are forced 
into the periapical tissues are serious consequences to be expected. 
Root-filling materials containing caustic drugs such as trioxi- 
methylen (paraform), etc., should never be employed; they usually 
cause necrosis when brought in contact with the soft tissues with 
all the undesirable sequences. Gutta percha in the form of cones 
or in its various semisolid modifications are frequently pressed into 
the periapical space during the process of root-filling. As stated, 
if the material is sterile and the protruding quantity does not 



_>|s DISEASES <>l THE DENTAL PULP 

impinge t<»<> severely upon the tissues it becomes incapsulated and 
no ill results are to !><• expected. Man} operators wilfully pass 
small quantities of gutta percha above the foramen, especially in 
such cases in which a crater-like depression is present at the apex 
of the root . The advocates of this procedure claim thai the capping 
of the crater is the only safeguard of having the rool canal com- 
pletely sealed. 

Immediate root-canal filling should never be practised in cases in 
which ;i pulp has been removed under local anesthesia; al leasl 
twenty-four hours should be allowed for the return <>f normal sen- 
sation of the disturbed periapical tissues. 



